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CORNELL UNIVERSITY.

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THE

ilostucll p. Homer Xibrarg

THE GIFT OF

ROSWELL P. FLOWER

FOR THE USE OF

THE N. Y. STATE VETERINARY COLLEGE.

1897

CORNELL UNIVERSITY LIBRARY

3 1924 104 224 542

The original of this book is in
the Cornell University Library.

There are no known copyright restrictions in
the United States on the use of the text.

http://archive.org/details/cu31924104224542

LIBRA? V

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THE

TECHNIC OF OPERATIONS

UPON THE

INTESTINES AND STOMACH

ALFRED H. GOULD, M.D.

OF BOSTON

With 190 Illustrations, Mostly Original
Several of Them in Colors

PHILADELPHIA AND LONDON

W. B. SAUNDERS COMPANY

1906

Mu\b%{

G&9

l J D .0 Q ,

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PRINTED IN PHILADELPHIA

PREFACE

Three years ago I began an experimental study of gastro-intestinal
technic. The animals used for the experiments were mainly dogs, although
cats were employed for certain operations.

The object of the experiments was to simplify, where possible, the best
gastro-intestinal operations. After careful study of an operation upon
animals, the method was tried again upon the cadaver, for anatomical
corrections.

In this book, which is the result of three years of research, are collected
certain of the standard operations upon the intestines and the stomach.

No pretence is made of giving all of the methods in vogue, and many
well-known operations have been omitted to give more room for illustrating
the methods which were chosen. It is believed, however, that a knowledge
of the technic, here included, will enable the surgeon to meet practically all
of the requirements of gastro-intestinal surgery.

I feel under the deepest obligations to Miss Florence Byrnes and to
Mr. H. F. Aitken for the painstaking manner in which they have made their
beautiful drawings. Certain of the drawings are modifications, or are copies
of others already in print; credit is given to such drawings in the legends.

Through the generosity of my publishers I am able to add seven
colored anatomical plates from Sobotta's "Atlas and Text-book of Human
Anatomy," which illustrate certain important surgical landmarks.

The work on repair, in Chapter I, was done conjointly with Dr. F. B.
Harrington, and is produced here with his permission. In fact, Dr. Harring-
ton's suggestions have been so numerous and so valuable that the scope
of the book has been greatly increased thereby. Prof. E. H. Nichols
first suggested and then directed the experiments for the study of repair, a
service for which I am greatly in his debt.

Through the kindness of Dr. F. T. Murphy I am able to reproduce his
original microscopical drawings, illustrating repair following the use of the
elastic ligature.

For the reproduction of the drawings upon the repair following the
Murphy button I am indebted to Dr. J. H. Barbat, of San Francisco, who

6 PREFACE

obligingly furnished me photographs of his sections, from which the draw-
ings were made.

The facts embodied in the discussion of intestinal localization are
taken from the monographs of Dr. G. H. Monks, by whose courtesy I have
been permitted to reproduce ten of his original drawings.

Dr. Mixter has been most obliging in allowing me to publish his technic
on colostomy, before he has done so himself.

The interest shown by Professors Warren and Burrell encouraged me
to attempt the task of writing a book, and their many kindnesses are grate-
fully acknowledged.

In the preparation of the manuscript, many works have been consulted,
among the authors of which are : Tillmann, Bickham, Robson and Moyni-
han, Gant, Cheyne and Burghard, Poirier, Delamere and Cuneo, Hartmann
and Cuneo, Terrier and Baudouin, von Frey, Binnie, Moynihan, Connell,
Gray, Quain, Testut, Tillaux, Sobotta, Stohr, Piersol, and many reprints.

Personal communications from Doctors Finney, McGraw, W. J. Mayo
and Connell have contributed valuable opinions which are embodied in the
text, where they are referred to in detail.

I wish to thank Dr. William C. Quinby for his careful correction of the
manuscript and of the proof.

48 Beacon Street, May, 1906.

Cbarles Burnbam Sorter, /ID.2).

FOR SIXTEEN YEARS

PROFESSOR OF CLINICAL SURGERY

HARVARD UNIVERSITY.

CONTENTS

CHAPTER I

PAGE

The Repair or Intestinal Wounds 17

The Structure of the Intestines and of the Stomach 17

The Blood-vessels of the Intestines and of the Stomach -. 19

The Lymph- vessels of the Intestines and of the Stomach 19

Experimental Research on Repair 20

Experiments with the Segmented Ring 20

Experiments with the Plain Suture 22

Repair Following the Use of the Murphy Button 47

Repair Following the Use of the Elastic Ligature 63

CHAPTER II

Suture Materials, Needles, Tying Knots, Sutures, and Clamps 65

Suture Materials 65

Needles 69

Tying Knots 70

Special Technic of Sutures 79

Clamps 98

CHAPTER III

The Anatomy of the Intestines 106

The Blood-supply of the Intestines : 106

The Lymphatics of the Intestines in

Intestinal Localization 1 14

CHAPTER IV

Operations upon the Intestines 128

Enterectomy 128

End-to-End Intestinal Anastomosis 130

Plain End-to-End Anastomosis 134

End-to-End Anastomosis by the Mattress Stitch 145

Mechanical Devices 149

Formation of a Blind End , 158

Suture in Two Layers 158

The Purse-string Operation 160

Lateral Intestinal Anastomosis 162

Plain Suture 162

The Mattress Suture 164

Mechanical Devices 165

IO CONTENTS

PAGE

End-to-side Intestinal Anastomosis *77

Colostomy 182

Left Inguinal Colostomy 183

Anterior Colostomy 186

Colostomy with the Rubber Ligature 188

Temporary Colostomy with Glass Tube 196

CHAPTER V

Operations upon the Stomach 201

Gastrotomy 201

Gastrostomy 202

Witzel's Gastrostomy 206

The Ssbanajew-Franck Gastrostomy 210

Pylorodiosis 211

Loreta's Operation 212

Hahn's Operation 217

Operations for Non-malignant Stricture of the Pylorus 218

Pyloroplasty 221

Gastroduodenostomy 222

Finney's Operation 225

Kocher's Operation 233

Gastroenterostomy 237

Posterior Gastroenterostomy 237

Anterior Gastroenterostomy 246

Pylorectomy 249

Partial Gastrectomy 269

Excision of Ulcer 276

Gastroplasty 281

Gastrogastrostomy 282

Gastroplication 293

Index or Names 295

Index 297

LIST OF ILLUSTRATIONS

FIGURE PAGE

i. Transverse Section of Human Stomach 18

2. Longitudinal Section of Human Jejunum 18

3 . End-to-end Anastomosis ; Three Days 25

4. Lateral Intestinal Anastomosis; Five Days 27

5. End-to-end Anastomosis; Eight Days 29

6. Gastroenterostomy; Twelve Days 31

7. End-to-end Anastomosis ; Fourteen Days 33

8. Gastroenterostomy; Twenty-one Days 35

9. End-to-end Anastomosis of Large Intestine; Six Weeks 37

10. Anterior Gastroenterostomy by Plain Suture; Seventeen Months after Opera-

tion 39

11. Peptic Ulcer of the Jejunum of a Cat; Proving Fatal Ten Months after Anterior

Gastroenterostomy 46

12. Cross Section of Peptic Ulcer of the Jejunum 49

13 . Repair Following the Use of the Murphy Button ; Three Days 51

14. Repair Following the Use of the Murphy Button; Thirty-six Days 51

15. Repair Following the Use of the Murphy Button; Forty-two Days 53

16. Repair Following the Use of the Murphy Button; Sixty-three Days 53

17. Section Across the Mass of Tissue Enclosed within the Loop of the Elastic Lig-

ature; Five Days' Duration 55

18. Section at Right Angles to the Line of Union of the Stomach and Jejunum;

Twelve Days' Duration : 57

19. Section at Right Angles to the Line of Union of the Stomach and Jejunum;

Thirty Days' Duration 59

20. Section Across an Adhesion; Seven Days' Duration, Which Had Formed Be-

tween the Edges of the Jejunum after the Elastic Ligature Had Cut Out 61

21. Method of Holding Curved Needle; Point Toward Operator 67

22. Method of Holding Curved Needle; Point Away from Operator 67

23. Milliner's Needle No. 3 69

24. Moynihan's Curved Needle, as Modified by Scudder 69

25. Method of Tying a Knot; First Step 70

26. Method of Tying a Knot; Second Step 71

27. Method of Tying a Knot; Third Step 71

28. Method of Tying a Knot; Fourth Step 72

29. Method of Tying a Knot; Fifth Step 72

30. Method of Tying a Knot; Sixth Step 73

31. Method of Tying a Knot; Seventh Step 73

32. Method of Tying a Knot; Eighth Step 74

12 LIST OF ILLUSTRATIONS

FIGURE PAGE

33. Method of Tying a Knot; Ninth Step 74

34. Richardson's One-hand Knot ; First Step 75

35. Richardson's One-hand Knot; Second Step 75

36. Richardson's One-hand Knot ; Third Step 76

37. Seamstress Knot; First Step 77

38. Seamstress Knot; Second Step 78

39. Seamstress Knot; Third Step 78

40. A Surgeon's Knot as it is Usually Tied 79

41 and 42. The Seromuscular Stitch 80

43. Cushing Right-angle Continuous Stitch; First Step 81

44. Cushing Right-angle Continuous Stitch; Second Step 81

45. Cushing Right-angle Continuous Stitch; Third Step 82

46. Cushing Right-angle Continuous Stitch; Fourth Step 83

47. The Lembert Stitch 83

48. Lembert Interrupted Stitch, with Cross Section 84

49. Lembert Continuous Stitch, with Cross Section 84

50. Halsted Mattress Stitch 84

51. Gould's Mattress Stitch 85

52. Halsted Mattress Stitch, with Cross Section 85

53 . Gould's Mattress Stitch, with Cross Section 86

54 and 55. Use of Reversed Mattress Stitch for Burying Stump of Appendix 86

56. The Purse-string Suture 87

57. The Purse-string Stitch; Cross Section 87

58. The Purse-string Suture for Lateral Anastomosis 88

59. Murphy's Purse-string Suture, Used for Button 88

60. Glover's Continuous Stitch, with Cross Section 89

61. The Buttonhole Stitch, with Cross Section 90

62. The Buttonhole Stitch Doubled go

63. Penetrating Mattress Stitch; Cross Section of One-half of Stitch 91

64. Maunsell's Mattress Mesenteric Stitch g 2

65 and 66. Two Views of the Small Intestine g?

67. Seromuscular Penetrating Mattress Stitch; Cross Section 95

68. Seromuscular Penetrating Mattress Stitch; Showing Stitch Pulled Tight 96

69. Straight Circumcision Clamp for Intestine gg

70. Rubber Tubing for Intestinal and Small Stomach Clamps 99

71. Maylard's Method of Using Forceps for Intestinal Clamps 100

72. Pean's Method of Using Hemostatic Forceps and Rubber Tube in Place of

Clamp 10I

73. Krause's Stomach Clamp IO ,

74. Gould's Stomach Clamp I0 ,

75. Scudder's Straight Stomach Clamp IO ,

76. Gould's Stomach Clamp I04

77. Harrington's Straight Stomach Clamp I04

78. Kocher's Crushing Clamp I04

79. The Blood-vessels of the Mesentery of the Small Intestine (Colors) 107

80. Showing Line of Mesenteric Root Traced on Abdominal Wall 115

LIST OP ILLUSTRATIONS 1 3

TIGURE PAGE

81. Showing Two Oblique Lines Drawn at Right Angles to the Two Extremities of

the Mesenteric Root 115

82. A Loop of Intestine, the Middle of Which is Exactly Three Feet from the End

of the Duodenum 119

83. A Loop of Intestine at Six Feet 119

84. A Loop of Intestine at Nine Feet 121

85. A Loop of Intestine at Twelve Feet 121

86. A Loop of Intestine at Seventeen Feet 123

87. A Loop of Intestine at Twenty Feet 123

88. Showing Monks' Method of Determining the Real Direction of the Gut 125

89. Showing How a Straight Instrument Passed into the Gut May Engage its Free

Border 132

90. End-to-end Intestinal Anastomosis 137

91. Showing Several Methods of Sewing Together the Cut Mesenteric Edges after

Resection of the Bowel 139

92. End-to-end Anastomosis; Mattress Mesenteric Stitch 139

93. End-to-end Anastomosis ; Sewing Mesenteric Third of Circumference 141

94. End-to-end Anastomosis ; Closing in the Last Third of the Circumference 141

95. End-to-end Anastomosis; Placing the Interrupted Lembert Stitches 143

96. End-to-end Anastomosis ; Suture Completed 143

97. Omental Graft 144

98. End-to-end Anastomosis, Connell Mattress; Showing Method of Placing the

Three Mattress Mesenteric Stitches 146

99. End-to-end Anastomosis, Connell Mattress ; Showing First Third of Bowel

Circumference Developed 147

100. End-to-end Anastomosis, Connell Mattress; Showing the Second Third of

Bowel Circumference Developed 148

101. End-to-end Anastomosis, Connell Mattress; Showing Closing in of the Last

Third of the Bowel Circumference 149

102. End-to-end Anastomosis, Connell Mattress; Showing Introduction of Last

Stitch 150

103. End-to-end Anastomosis ; Showing Introduction of Murphy Button 151

104. End-to-end Anastomosis ; Showing Button Halves Snapped Together 151

105. End-to-end Anastomosis ; Harrington's Segmented Ring 155

106. End-to-end Anastomosis, Harrington's Segmented Ring; Showing Purse-

strings and Mattress Mesenteric Stitch 156

107. End-to-end Anastomosis, Harrington's Segmented Ring; Showing Continuous

Seromuscular Suture 156

108. End-to-end Anastomosis ; Robson's Decalcified Bone Bobbin 158

109. Formation of Blind End; Inner Continuous Glover's Stitch 159

no. Formation of Blind End; Outer Layer of Reversed Mattress Stitches 159

in. Formation of Blind End; Purse-string in Position 161

112. Formation of Blind End; Invagination and Purse-string Tied 161

113. Formation of Blind End; Cross Section 161

114. Lateral Intestinal Anastomosis 163

115 an d II6 - Lateral Anastomosis with Jaboulay's Button 167

14 LIST OF ILLUSTRATIONS

FIGURE PAGE

117. McLean Needle for the Rubber Ligature 17 1

118. Lateral Anastomosis by McGraw Ligature; First Seromuscular Stitch Placed.. 174

119. Lateral Anastomosis by McGraw Ligature; Ligature being Drawn Taut 175

120. Lateral Anastomosis by McGraw Ligature; Showing the Three Stages of the

Technic *75

121. Lateral Anastomosis by McGraw Ligature; Cross Section 177

122. Lateral Anastomosis by McGraw Ligature; Showing Actual Opening 177

123. End-to-side Anastomosis, Gould's Method; Showing First Mattress Stitch 179

124. End-to-side Anastomosis, Gould's Method; Showing First Mattress Stitch Tied. 179

125. End-to-side Anastomosis, Gould's Method; Showing Suture Nearly Completed. . 179

1 26. End-to-side Anastomosis ; Cross Section 181

127. Left Inguinal Colostomy; Showing Line of Incision 183

128. Left Inguinal Colostomy; Showing Method of Placing Stitches 184

129. Left Inguinal Colostomy; Showing Coils Drawn Together by Mesenteric Stitch. 185

130. Left Inguinal Colostomy; Showing Afferent and Efferent Coils Amputated 186

131. Mixter's Anterior Colostomy; Showing Line of Incision 189

132. Anterior Colostomy; Showing Flap of Skin and Subcutaneous Tissue 189

133. Anterior Colostomy; Showing Sigmoid withdrawn and Mesentery Incised 191

134. Anterior Colostomy; Showing Flap Fastened 193

135. Anterior Colostomy; Showing Sigmoid Resected 193

136. Cross Section of Anterior Colostomy (Horizontal) 195

137. McGraw's Colostomy with Resection; Rubber Ligature Placed 197

138. McGraw's Colostomy with Resection; Resection Completed 197

139. McGraw's Colostomy with Resection; Line of Original Incision 199

140. Gastrotomy 203

141. Witzel's Gastrostomy; Catheter Partly Buried in Stomach 207

142. Witzel's Gastrostomy; Eye of the Catheter Inserted in Stomach 207

143. Witzel's Gastrostomy; Stomach Fastened to Anterior Abdominal Wall 209

144. Witzel's Gastrostomy; Cross Section 209

145. Ssbanajew-Franck Gastrostomy; Lines of Incision 211

146. Ssbanajew-Franck Gastrostomy; Bridge of Skin Dissected Up 213

147. Ssbanajew-Franck Gastrostomy; Cone of Stomach Held in Place with Forceps . . 213

148. Ssbanajew-Franck Gastrostomy; Skin Closed Over Base of Cone 215

149. Ssbanajew-Franck Gastrostomy; Cross Section 215

150. Pylorodiosis, Hahn's Method; Steadying Pylorus 218

151 and 152. Heinecke-Mikulicz Pyloroplasty 223

153. Relations of the Posterior Abdominal Wall (Colors) facing 226

154. Mobilization of the Second Portion of the Duodenum 228

155. Finney's Gastroduodenostomy; Showing Application of Clamps 229

136. Finney's Gastroduodenostomy; First Seromuscular Suture 230

157. Finney's Gastroduodenostomy; Inner Continuous Through-and-through Suture 231

158. Finney's Gastroduodenostomy; Cross Section before Operation 232

159. Finney's Gastroduodenostomy; Cross Section after Operation 232

160. Kocher's Gastroduodenostomy 231;

161. Relations of the Great Omentum and the Stomach (Colors) facing 238

162. The Great Omentum Turned Up Exposing the Small Intestines (Colors) . .facing 238

LIST OF ILLUSTRATIONS 1 5

FIGURE PAGE

163. Transverse Colon Lifted Up Over the Thorax (Colors) lacing 238

164. The Small Intestine Cut Off (Colors) facing 238

165. Posterior Gastroenterostomy; Clamps Applied 239

166. Posterior Gastroenterostomy; Inner Through-and-through Suture 242

167. Posterior Gastroenterostomy; Completed 243

168. Gastroenterostomy; Cross Section 245

169. Diagram, Anterior Gastroenterostomy 247

170. The Blood Supply of the Stomach (Colors) 251

171. The Lymphatic Drainage of the Stomach, to Illustrate Cuneo's Division into

Territories (Colors) 253

172. Relations Around the Head of the Pancreas (Colors) facing 258

173. Pylorectomy; Showing Gastric and Pyloric Arteries Tied and Cut 259

174. Pylorectomy, Showing Section of Duodenum Between Clamps, Distal End

Partly Closed in 261

175. Sound Introduced Through the Foramen of Winslow (Colors) facing 264

176. Gastrocolic Omentum Cut and Stomach Lifted; Exposing the Lesser Peritoneal

Cavity (Colors) facing 264

177. Pylorectomy; Showing Extension of Growth 265

178. Pylorectomy; Showing Method of Holding the Scissors 266

179. Pylorectomy; Showing Distal End of Duodenum Wholly Closed in 267

180. Resection of the Middle Portion of the Stomach; Showing Harrington's Straight

Clamps in Position 271

181. Resection of the Middle Portion of the Stomach; Showing End-to-end Anasto-

mosis after Resection 273

182. Resection of the Middle Portion of the Stomach; Showing Suture Completed. . . 275

183. Resection of an Ulcer on the Lesser Curvature; Showing Clamps and Vessels Tied 277

184. Resection of an Ulcer on the Lesser Curvature; Showing Posterior Edges of

Wound Approximated 279

185. Gastroplasty for Hour-glass Stomach 281

186. Gastroplasty 283

187. Gastrogastrostomy for Hour-glass Stomach 285

188. Gastroplication ; Showing Method of Placing the Stitches 287

189. Gastroplication; Showing Anterior Wall Plaited 289

190. Gastroplication; Cross Section 291

THE

TECHNIC OF OPERATIONS

UPON THE

INTESTINES AND THE STOMACH

CHAPTER I.
THE REPAIR OF INTESTINAL WOUNDS.

THE STRUCTURE OF THE INTESTINES AND OF THE STOMACH.— THE BLOOD-
VESSELS OF THE INTESTINES AND OF THE STOMACH.— THE LYMPH- VESSELS OF
THE INTESTINES AND OF THE STOMACH.— EXPERIMENTAL RESEARCH ON REPAIR.

THE STRUCTURE OF THE INTESTINES AND OF THE STOMACH.

(Figs, i and 2.)

In order to understand the repair of intestinal wounds, a knowledge
of the histology of the gastrointestinal canal is necessary. A brief de-
scription of the histology of these organs is given below, which has been
taken, chiefly, from Stohr 1 and Piersol. 2

The stomach and the small and the large intestines are composed of
four coats, the serous, the muscular, the submucous, and the mucous.
Although the characteristics of the individual layers change somewhat
according to the digestive functions which they are required to perform,
these variations are not of importance in the process of repair.

The external, or serous, coat is derived from the peritoneum, and
"consists, principally, of fibrous connective tissue and numerous elastic
networks; the free surface is covered by a simple layer of flat polygonal
cells" (Stohr).

1 Stohr. Text-Book of Histology, p. 162.
3 Piersol. Normal Histology, p. 174.

INTESTINAL AND GASTRIC OPERATIONS.

The muscular coat consists of a thick inner circular layer, and a thin
outer longitudinal layer. In the stomach the arrangement is varied by the
addition of a third layer of oblique fibers, which is derived from the esoph-
agus. In the colon the longitudinal muscle-fibers are collected mainly

.Mucosa,.

Mascularls
\ Mucosae.

} ouhmucosa-.

1 Inner circular
layer of
Mhele

longitudinal
layer of
muscle.

J Serosa-.

Fig. i. — Transverse Section oy Human Stomach. X 16. (After Stohr.)

Mucosa.

\ ouh/nuxosa.
I \ Inner circular
\ Outer lo)iyitu.dinjLL

Fig. 2.

} Serosa,.

-Longitudinal Section or Human Jejunum, x 16. (After Stohr. 1

into three flat bands which are placed on the mesenteric, the anterior, and
the inner borders of this portion of the large intestine.

The submucous coat is composed of loosely united connective tissue-
bundles, and elastic fibers, and occasionally contains small clusters of fat
cells.

THE REPAIR OF INTESTINAL WOUNDS. Ig

The internal, or mucous, coat is soft, highly vascular, and covered
with epithelium which varies markedly according to its situation in the
digestive tube. In it are placed the glandular elements which take part in
the digestive process. The glandular layer of the mucous membrane is
separated from the submucosa by two thin layers of smooth muscle-fibers
called the muscularis mucosa, and, from this layer, other muscle-fibers
are given off which interlace among the glands of the mucous layer proper.
The muscularis mucosas achieves its great importance from its tough
structure, which is peculiarly adapted to resist the pull of a stitch. It is
the only portion of the intestinal wall which has this valuable quality.

THE BLOOD-VESSELS OF THE INTESTINE AND OF THE STOMACH. 1

The blood-vessels of the stomach and of the large intestine have a
precisely similar distribution, which is modified in the small intestine by
the presence of the villi.

Upon entering the serosa of the stomach and of the large intestine the
arteries give off small branches to the serosa, thence, piercing the muscu-
laris, which they also supply, they pass to the submucosa to form a network
which is placed within this layer parallel to the surface of the bowel. In the
healing of intestinal wounds it will be seen later that the vessels which take
the most active part in the process arise from the submucosa.

The small branches which arise from the submucous plexus ascend
through the mucous membrane and from another network in the tunica
■propria at the base of the glands. The gland-tubules and crypts are sup-
plied from this plexus.

The vessels of the small intestine which supply the crypts are distrib-
uted in the same manner as in the large intestine. The vessels are other-
wise changed to adapt themselves to the special anatomy of the small in-
testine, — i. e., villi, glands of Brunner, lymph-nodes, etc.

THE LYMPH-VESSELS OF THE INTESTINES AND OF THE STOMACH. 2

The lymph-vessels of the stomach and of the large intestine take their
origin in the mucous membrane as blind capillaries, and descend between

1 Stohr. Text-Book of Histology, p. 168.

2 Stohr. Text-Book of Histology, p. 169.

20 INTESTINAL AND GASTRIC OPERATIONS.

the gland-follicles. In the mucous membrane of the small intestine the
lymph-vessels begin in the axes of the villi. All these vessels descend
and join in a capillary plexus lying at the base of the glands. This plexus
extends parallel to the surface and communicates by numerous anasto-
moses with a wide-meshed plexus in the submucosa. Proceeding from
this network, the lymph-vessels penetrate the muscular coat, receiving trib-
utaries from the plexus situated between the circular and the longitu-
dinal muscular strata, the so-called intramuscular lymphatic plexus, which
receives the lymph supply from both muscular layers. The vessels run
beneath the serous coat to the mesenteric border, and pass on between its
layers.

EXPERIMENTAL RESEARCH ON REPAIR.

The study of repair which follows was done with Dr. F. B. Harrington
in the Laboratory of Surgical Pathology at Harvard Medical School. 1
The data was obtained from three sources:

(i) A series of twenty-two experiments upon fourteen dogs and four
cats. In these animals the anastomoses were made with the assistance
of the Harrington segmented ring.

(2) A series of experiments upon ten cats and three dogs. These
experiments were not done primarily for the study of repair, but had
in view the working out of certain technic in the operation of gastroenter-
ostomy. These experiments were done without the aid of a mechanical
device. Specimens taken from these animals were used for comparison
with the first series.

(3) Sections of anastomoses done on human beings, kindly furnished
by Dr. Nichols.

EXPERIMENTS WITH THE SEGMENTED RING.

The technic for introducing the ring and performing the anastomosis
is briefly as follows:

(1) The cut bowel-ends are fastened over the ring by means of soluble
purse-string sutures. These sutures perform the double duty of attaching
the bowels to the ring, thus facilitating the introduction of the mesenteric

1 Harrington and Gould. Annals of Surgery, November, 1904.

THE REPAIR OF INTESTINAL WOUNDS.

and the peritoneal stitches, as well as of holding the segments of the ring
together during the first four or five days succeeding the operation.

(2) The Maunsell mattress-mesenteric stitch is used to bring together
the mesenteric borders, after tying the purse-strings.

(3) The peritoneum is approximated with a continuous Cushing right-
angle suture. The suture material used for the purse-strings was No. 2
plain catgut; for the mattress-mesenteric stitch, No. 1 chromic catgut; for
the Cushing right-angle stitch, No. 1 Pagenstecher's celloidin linen thread.
A complete illustrated description of the three stitches mentioned above
is to be found in Chapter II.

TABLE OF EXPERIMENTS WITH THE SEGMENTED RING.

End-to-end intestinal anastomoses 8

Lateral intestinal anastomoses 3

Gastrointestinal anastomoses 7

— 18
Gastrogastrostomies 4

End-to-end. (Dogs.)

Time
Exp. elapsed after
operation.

i day
i day
3 days
7 days

7 days

8 days
14 days
42 days

Condition of suture
at autopsy.

Intact

Slough of suture, too large ring 1

Intact

Segments found.

At site of suture.

Ileum.

Two in ileum, two in rectum.

Ileum and rectum.

Not found (passed).

10.

S days
10 months
12 months

Intact
Still alive
Still alive

Lateral Intestinal. (Dogs.)

Near suture.

12.

13-

14-

IS-
16.

i7-

3 days
7 days
7 days
10 days
12 days
14 days
21 days

Gastroenterostomies. (Dogs.)

Intact Three in pylorus (stomach), one in small

Intact Ileum. [intestine.

Intact Ileum.

Intact Rectum.

Intact Large intestine and rectum.

Intact Three in large intestine and rectum.

Intact Not found (passed).

1 The intestine in this case was so stretched over the ring that it was anaemic. As it was an
early case, the importance of breaking down the ring under such circumstances was not recog-
nized.

INTESTINAL AND GASTRIC OPERATIONS.

Gasteogasteostomies. (Cats.)
To determine how long ring remains in situ.

24 hours

Intact

3 days

Intact

S days

Intact

A-

6 days

Intact

Segments held firmly in place.
Segments held firmly in place.
Segments still in place, loosely.
Ring broken down, segments all in situ.

EXPERIMENTS WITH THE PLAIN SUTURE.
When an anastomosis is performed without the aid of a mechanical
device it is customary to employ two layers of stitches : an inner continuous
stitch which penetrates all coats, and brings together the cut edges ; an outer
stitch, either continuous or interrupted, for approximating the peritoneal
surfaces around the joint. The second series of experiments of ten cats
and three dogs was done with the plain suture technic.

TABLE OF EXPERIMENTS WITH THE PLAIN SUTURE.

Time elapsed

Condition of suture

Expt.

after operation.

at autopsy.
Cats.

Operation.

15 hours.

Intact.

Anterior Gast. Ent.

24 hours.

Intact.

Anterior Gast. Ent.

3 days.

Intact.

Anterior Gast. Ent.

7 days.

Leak.

Anterior Gast. Ent.

17 days.

Intact.

Anterior Gast. Ent.

21 days.

Intact.

Anterior Gast. Ent.

39 days.

Intact.

Anterior Gast. Ent.

6 weeks.

Intact.

Anterior Gast. Ent.

10 months.

Intact.

Anterior Gast. Ent.

17 months.

Intact.
Dogs.

Anterior Gast. Ent.

3 weeks.

Intact.

Posterior Gast. Ent.

6 weeks.

Intact.

Anterior Gast. Ent.

16 weeks.

Intact.

Posterior Gast. Ent.

The repair following the use of the two layers of stitches was found
to be practically identical with that following the use of. the ring, thus
showing that an inner layer of stitches has little influence upon the healing
of the wound. The facts given below may be regarded, therefore, as
characteristic of repair succeeding the use of the plain suture in two layers,
as well as after the use of mechanical devices which demand but one layer
of sutures. Three drawings were made from this series.

The sections taken from human beings were four in number, and
consisted of end-to-end anastomoses, of two days, four days, seven days,
and ten days, respectively.

THE REPAIR OF INTESTINAL WOUNDS. 23

Details of the Repair. — The close approximation of two serous surfaces,
which is characteristic of intestinal sutures, results in a rapid exudation
from the apposed surfaces. This exudation appears in a very few hours
and hermetically seals the wound. Every coat of the bowel is soon pene-
trated by this exudate, rapidly destroying the endothelium on the outside
of the bowel.

Repair of the Mucous Membrane.— For the first few hours after the
suture the mucous membrane is the seat of a marked active hyperemia
with more or less bloody extravasation, the mucous edges being dark red
and elevated from the coats below. This condition is followed by an exu-
dation which extends into the glandular tissue until, at the end of three
days, the glands disappear about the cut edge for two to five millimeters.
When a large invagination has been made, in the process of suture, the sub-
mucosa becomes so swollen and edematous that it probably interferes
thereby with the circulation of the mucous membrane. Under such con-
ditions the slough of the mucous membrane is correspondingly extensive.
The amount of destruction of mucous membrane varies somewhat; but
usually the slough is about three to five millimeters in width. At the end
of five days, the slough generally separates, leaving a clean line. The above
series of changes takes place in all sutures, although a separate suture of
the mucous membrane seems distinctly to retard the repair for reasons
given later.

The reproduction of glands is more rapid in end-to-end than in lateral
sutures. If the inturn has been a moderate one, the mucous membrane
will cover in the ulcer in about eight days. The glands themselves, though
atypical in shape, possess all the characteristics of mucous glands. At the
end of eight days the line of suture is represented by a narrow scar situated
in the middle of what was formerly the ulcerated area. After gastroenter-
ostomy and lateral intestinal suture, the cleaning away of the slough takes
place quickly; but the subsequent ingrowing of the mucous membrane is
slow, since the interval to be crossed is a wide one. The process is exactly
analogous to the healing of a superficial ulcer on the surface of the body.
In these cases mitotic figures were seen at the end of five, but were numer-
ous only at the end of ten days. The nuclear division, as a rule, first came
in the mucosa of the stomach. On the tenth day a single line of cells starts

24 INTESTINAL AND GASTRIC OPERATIONS.

from the stomach and rapidly crosses the floor of the ulcer. The complete
closing in of the bare area is much hindered by the presence of sutures,
which, even though absorbed, leave irregular holes that are but slowly
smoothed over. At the end of twenty-one days the line of suture is cov-
ered by a continuous though low mucous membrane. The line of demar-
cation between the stomach and intestinal glands is a sharp one, and is
situated near the center of the old ulcer. These glands, though atypically
shaped, have normal functional power (goblet cells, etc.) (Figs. 3 to 10
inclusive) .

The new mucous membrane has no definite muscularis mucosae. At
first it rests upon a base of dense granulation tissue. This coat is very slow
to repair; but, at the end of six weeks, a substitute muscularis mucosa? has
been acquired, which consists largely of connective tissue, but in which are
found fibers closely resembling smooth muscle. This layer has no sharp
limits, and fades away into the scar tissue beneath.

Repair of the serous surfaces. — The formation of plastic exudate
does not cease with the resulting adhesion of the inturned serous coats, but
appears externally for a distance of three to five centimeters beyond the line
of suture, thus acting like an external callus. The transformation of the
exudate into granulation tissue is rapid. In three days a large number of
new connective-tissue cells have been laid down, among which are a few
new blood-vessels arising from the vessels in the underlying muscular coat.
Entire organization of the inner exudate requires at least seven, the outer
at least ten, days. After complete organization, the connective tissue
gradually disappears, finally remaining as a thick scar, which reaches for
a varying distance over the adjacent bowel and, dipping down into the
depth of the suture, holds the bowel walls firmly together by thick strong
bands. Fourteen days are required for the completion of this sequence.

Repair of muscular coats. — The muscular coats play a passive role
during the first forty-eight hours after the suture. The muscle-bundles
are penetrated by extravasated blood and by exudate throughout their
whole thickness. After the second day new blood-vessels bud out into the
exudate and assist in its organization. When the inflammatory process
has subsided, the muscle-ends are held together by scar tissue arising from
the intermuscular connective tissue. This rapidly contracts and approxi-

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Fig. 7. — End-to-end Anastomosis, Fourteen Days.
Marked diaphragm. Granulation tissue contracted down to a dense scar. Diaphragm entirely
covered by newly formed atypical glands. Marked inequality in the amount of the intestine inverlcd
on the two sides.

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Fig. io. — Anterior Gastroenterostomy, by. Plain Suture, Seventeen Months after Operation.
Note the great width of the submucosa, that the muscularis mucosa? has not yet reproduced itself;
that the peritoneal surface of the anastomosis has disappeared, the latter being due to adhesion to the
omentum. The omental adhesions have been lost in making the section.

THE REPAIR OF INTESTINAL WOUNDS. 41

mates the separated muscle-ends, so that the ultimate scar is an extremely
narrow one and may be entirely unrecognizable by the naked eye.

Repair of the submucosa. — The loose texture of the submucosa
allows easy entrance to the exudate. Almost at once this layer becomes
distended and edematous for several centimeters on either side of the wound.
At the end of the inturned bowel this layer is often as thick as all the others
combined. As organization proceeds, the submucosa is filled with large
and small blood-vessels and young connective-tissue cells which, running
parallel to the surface of the bowel, grow out into the exudate in the bottom
of the ulcer, thus forming the base of the internal ulcer. Ultimately the ulcer
is converted into scar tissue and is covered by an atypical mucous mem-
brane. From comparison with a limited number of clinically successful
intestinal anastomoses in human beings, it seems that the analogy of the
process in these animal experiments and in human beings is a very close
one, both in histological and in gross appearances.

Mall's experiments. — Mall's experiments 1 with animals, in 1887,
led him to divide the repair of intestinal wounds into the following stages :

(1) An immediate fibrous union of the serous surfaces.

(2) A destruction of the protruding parts between the two flaps of the
mucosa. This destruction is brought about in two ways: a, necrosis, b, the
destroying power of those crypts which have returned to their embryonic type. 2

(3) Regeneration of the mucous membrane. Soon after the intestine
is sutured, the cut ends of the mucous membrane are destroyed. The bases
of the crypts, however, seem to be more resistant and soon show many
karyokinetic figures within the epithelial cells. The multiplication of cells
in this portion, which is probably only an exaggeration of the normal
process, soon causes this layer to spread in all directions. These cells
cover the whole surface within their reach, besides sending cystiform
invaginations into the tissue. This growth continues until it meets cells
from the opposite side, when, of course, it cannot go further. The epithelial

1 F. Mall. Johns Hopkins Hospital Reports, Vol. I, p. 76.

2 Ibid. Mall explains more fully in the text the process by which these crypts return to the
embryonic type. When the submucosa is torn by the needle, a fissure 'is made which heals by
granulation. In the granulation tissue filling these fissures the crypts are frequently embedded,
being lined with a single layer of cells of the embryonic type. This is shown in Figs. 4 and 8 of
my sections.

42 INTESTINAL AND GASTRIC OPERATIONS.

covering at once sends invaginations into the tissue which are converted
into crypts, between which newly formed villi arise and grow into the
lumen of the intestine. If the conditions are favorable, the mucous mem-
brane is fully regenerated at the end of three weeks.

(4) Straightening of the suture. During the fourth week the stitches
begin to lose their hold in the submucosa, thus allowing the intestine to
straighten out. While the regeneration of the mucosa is taking place, the
submucosa of one side is being united by fibrous tissue with the submu-
cosa of the other. The straightening of the suture now allows the ends of
the muscle-coats to be arranged in a straight line, besides placing the
embryonic mucosa under a greater pressure, thus favoring its maturation.
Before the straightening is complete there is a regeneration of muscular
tissue, most marked in the muscular is mucosae.

The stratum fibrosum 1 is most resistant and does not begin to regener-
ate until the sixth week. Up to this time its edge is marked by a sharp
border, which, during the sixth week, becomes less defined and projects
across the line of suture.

At the end of two months all the coats are fully regenerated and the
line of suture can hardly be made out microscopically, while macroscopic-
ally it is marked by a thickening of the intestinal walls.

In comparing Mall's results with my own, a few discrepancies will be
found. I have not been able to demonstrate repair of the muscularis mucosee
in any specimen, whether done with the segmented ring or by plain suture.
On the contrary, Mall's sections showed that both strata of muscle-fibres
which make up this layer had been reproduced. Attention is called to
Fig. 10, a specimen obtained seventeen months after operation (gastro-
enterostomy). The scar joining the cut ends of the muscularis mucosas
consists wholly of connective tissue; there is no evidence whatever of
muscle-fibres at the point of union.

The time required for the regeneration of the mucous membrane with
closure of the internal ulcer, was rather longer in Mall's specimens than
in my own. In the latter the internal ulcer was covered with mucous
membrane in seven days, as a rule, though this layer continued to grow in
thickness for another week. The period set by Mall for complete regener-

1 For the histology of the dog's intestine see Abhandl. d. K. S. Ges. d. Wiss., 1887, Bd. xiv.

THE REPAIR OF INTESTINAL WOUNDS. 43

ation of the mucous membrane is three weeks, but a comparison is unsatis-
factory since the exact moment of complete restoration of the mucous mem-
brane is impossible to determine.

Loosening of the seromuscular stitches, with consequent straightening
of the joint, was not seen in any of my experiments, although observed
by Mall four weeks after the original anastomoses. Other than the dif-
ferences mentioned above, the facts observed in the two series of experi-
ments are practically identical.

Peptic Ulcer of the Jejunum. — One of the rare complications which
follows gastroenterostomy is peptic ulcer of the jejunum. Tiegel 1 has
collected twenty-two cases of this sort. He omitted, however, to include
in his list two cases described by Robson 2 in 1904, which makes a total of
twenty-four reported cases.

Frequency. — Kausch 3 in 1900 reported two cases in a series of one
hundred and sixty gastroenterostomies done in the clinic of Professor
Mikulicz. As reported by Watts 4 this is probably too small a proportion.

The age of the patients varied between four months (Mikulicz's case)
and fifty-nine years, the majority of the patients, however, being more than
thirty years old and of the male sex.

Etiology. — Tiegel calls attention to the fact that the original gastro-
enterostomy was always done to relieve benign disease of the stomach,
usually pyloric stenosis. In one case the stenosis was congenital, in another
the ulcer was in the duodenum. The acidity 0} the gastric juice has always
played a prominent role in the theoretical explanation of the cause of peptic
jejunal ulcer. In Tiegel's series the stomach contents were examined in
only a small number of cases. The results showed that hydrochloric acid
was present in excess in some, while in others it was diminished, the ma-
jority being in the favor of hyperacidity. Certain cases which were ex-
amined in the interval between the first operation and the onset of the
symptoms of secondary ulcer, showed some subacidity, others hyperacidity.

Robson 5 believes that the true cause of peptic ulcer, whether gastric,

1 Tiegel. Mittheilungen a. d. Grenzgeb. der Med. und Chir., Vol. xm, 1905, p. 897.

2 Robson. Annals of Surgery, 1904, Vol. XL, p. 186.

3 Kausch. Verhandl. d. Deutsch. Gesellsch. fur Chir., Bd. xxvm, 1899, S. 74; Bd. xxrx,
1902, S. 140, and Bd. xxxi, 1902, S. 115.

4 Watts. Johns Hopkins Hospital Bulletin, July, 1903. R Robson. Loc. cit.

44 INTESTINAL AND GASTRIC OPERATIONS.

duodenal, or jejunal, is probably due to a mild form of sepsis which leads
to gastritis and an excess of hydrochloric acid in the gastric juice.

Kocher 1 thinks that the acid gastric juice may stimulate circular con-
traction of the duodenum just below the stomach with the formation of
a kind of cul-de-sac where contact with the gastric juice may be prolonged,
and give rise to ulceration. He claims to have seen such contractions
several times in cases of gastroenterostomy which he has explored.

Traumatism of the abdomen preceded one of Hahn's 2 cases, and for
this reason was believed by him to have led directly to the condition.

On the whole we can draw no definite conclusion in regard to the etio-
logical significance of hyperacidity of the gastric juice.

Tiegel regards the effect of circulatory disturbances upon the attached
intestine as important possible causes of secondary ulcer (Virchow 3 ).
Some light is shed on the subject by noting the methods used for perform-
ing the primary gastroenterostomy. In sixteen cases (eighteen, with
Robson's two cases), the anterior method of anastomosis was adopted, in
seven of which an additional enteroenterostomy was done, including one
Y operation of Roux. In five cases the operation was retrocolic and pos-
terior, but with a longer intestinal loop than that used at the present.

Welch 4 found that out of 793 cases of peptic ulcer of the stomach,
collected from the statistics of the Johns Hopkins Hospital, 288 were on the
lesser curvature; 235 on the posterior wall; 95 at the pylorus; 69 on the
anterior wall; 50 at the cardia; 29 at the fundus, and 27 on the greater
curvature. It is worth noting that, although peptic ulcer of the stomach is
most frequently found on the lesser curvature and the posterior wall, peptic
jejunal ulcer nearly always comes after an anterior operation.

The site of the secondary ulcer in Tiegel's series was as follows: In
10 instances it was found near the gastric stoma; in 1 near the opening of
the enteroenterostomy; in 10 cases it was in the jejunum, separated one to
seven centimeters from the gastroenterostomy opening; in 3 cases the ulcers
were multiple, in 7 there were also ulcers in the stomach.

1 Kocher. Verhandl. d. Deutsch. Gesellsch. fur Chir., Bd. xxxi, 1902, S. 103.

- Hahn. Ibid., Bd. xxviii, 1899, S. 74, and Bd. xxxi, 1902, S. 114.

3 Virchow. Virch. Arch., Bd. 5, S. 362.

1 Welch. Pepper's System of Medicine, 1885, Vol. 11, p. 482.

THE REPAIR OF INTESTINAL WOUNDS. 45

It is probable that the jejunum is more open to circulatory disturbances
when attached by the anterior than by the posterior method, in view of the
statistics of 18 anterior against 5 posterior. Tiegel suggests that the circu-
lation may be impeded in several ways. The coil which passes in front of
the transverse colon may be too short and, therefore, be subjected to tension
from stretching, or else kinks may occur in the mesentery itself and cut off
a part of the blood supply. Another factor contributing to restrict the
blood supply of the jejunal coil is arteriosclerosis. In one of Steinthal's
cases marked atheroma was associated with a slight kinking of the mes-
entery. Direct injury to the mucous membrane has been mentioned as a
cause of peptic jejunal ulcer. This may occur at the time of operation,
from manipulation of the instruments, or it may come later from
scratching the mucous membrane with hard particles of food.

In comparing the human with the two reported experimental cases it
will be seen that analogous results have been obtained. In the cases of
Watts (dog), and of the author (cat), the primary operations were both
anterior gastroenterostomies. It will be remembered that, as far as position
goes, the anterior wall of the quadruped stomach corresponds to the
greater curvature of human beings, and that the posterior gastroenter-
ostomy in man is the nearest approach to the anterior gastroenterostomy
in animals. 1 However, the position of the four-footed animal allows the
stomach to press downward upon the anastomosis, and this might lead to
circulatory disturbance by pressure, kinking, or stretching, as in the
human being.

Pathology. — Tiegel states that growth of a peptic ulcer of the jejunum
is a process wholly similar to the formation of a peptic ulcer of the
stomach. There is first an effusion of blood into the mucous membrane,
usually of small extent, followed later by death and digestion of the affected
area. As Steinthal has observed, the loss of substance extending only
through the mucous membrane, at first, finally reaches down through all
the layers of the intestinal wall. In cases which take a very acute course
the shape of the ulcer is round, and the walls smooth and steep. The
more slowly advancing lesions, on the contrary, attack the layers sepa-
rately, so that the walls of the ulcer are terraced. Finally, a secondary

1 Cannon and Blake. Annals of Surgery, May, 1905.

4 6

INTESTINAL AND GASTRIC OPERATIONS.

inflammatory reaction is set up which obscures more or less the character-
istics of the original lesion. The ulcer walls become infiltrated, tumefied,
and firm; and the shape of the ulcer irregular. In cases of longer duration
adhesions form with neighboring organs, into which the ulcer finally per-
forates. According to Lennander 1 (quoted by Tiegel), no pain-perceiving
nerves are situated in the stomach or intestine. Diseases of these organs
produce no pain unless the process has reached the peritoneum. For this
reason there may be a perforation of the ulcer without previous symptoms.
The drawings shown are from a specimen taken from the second series.
The animal was an undersized female cat. The operation was an anterior

Fig. ii. — Peptic Ulcer of the Jejunum of a Cat, Proving Fatal Ten Months after Anterior

Gastroenterostomy.
By looking down through the stoma, the jejunum can be seen. Note entrance and exit of proximal
and distal coils, respectively. About entrance of proximal coil is a. large punched-out ulcer covering
half of the patch of jejunum. This ulcer extends out beneath the line of suture.

gastroenterostomy done with clamps, the incision being four centimeters
in length; linen thread was used for both layers of sutures. The animal
remained in good health for eight months after the operation, after which
it began to fail rapidly, with symptoms of pain, vomiting, and cramps of the
abdominal muscles. The cat died of marasmus ten months after operation.

1 Lennander. Cent, fur Chir., 1901, S. 209.

THE REPAIR OP INTESTINAL WOUNDS. 47

Fig. 11 is a drawing from the gross specimen. The stomach has been
opened and its walls cut away up to within a short distance of the anasto-
mosis, showing the jejunal patch blocking the stoma in the anterior gastric-
wall. An examination of the portion of the jejunum underlying the gastric
opening shows it to be the seat of an extensive punched-out ulceration about
the entrance of the proximal coil. The ulceration has extended laterally
into the gastrointestinal suture line, thus undermining the latter's edge for
a distance of one-eighth to one -half inch. It is important to observe that,
although the ulcer was situated exactly at the suture line, no contraction of
the stoma had resulted, the opening of four centimeters originally made at
the operation being found the same at death.

The microscopical section (Fig. 12) explains well the condition of affairs.
Apparently the mucous membrane of the stomach, adjacent to the ulcer,
is normal, since no thickening or excoriation is to be seen. The sides of
the ulcer are punched out sharply, while at the junction of the sides with
the base a deep excavation extends out beneath the edges of the ulcer. In
the base of the ulcer little of the jejunal tissue can be found, its normal
structure being replaced by a thin layer of granulation tissue. Within the
granulation tissue are embedded a few muscle-fibers, but it is evident that
the ulcer had completely cut through all coats of the jejunum. The activity
of the repair in responding to the irritation of the lesion had 'resulted in the
formation of a provisional base for the ulcer, thus preventing immediate
perforation. It is probable that this provisional base would not have con-
trolled the advance of the ulceration had the animal survived the marasmus.

REPAIR FOLLOWING THE USE OF THE MURPHY BUTTON.

It is hardly necessary to explain the application of the well-known
Murphy button. It suffices to say that anastomosis is accomplished by
fastening a button half into each open intestinal end. The button is so
constructed that, by snapping the halves together, the peritoneal surfaces
of the circumference of the bowels are brought nicely together, and held
until firm adhesions have bound the ends one to the other. The portions
of bowel, which are jammed between the halves of the button, slough, thus
freeing the instrument, which passes out per anum.

Barbat 1 has paid attention to this technic and has published a detailed
1 Barbat, J. H. Journal Am, Med. Asso., July 15, 1899.

48 INTESTINAL AND GASTRIC OPERATIONS.

account of the method in which intestinal union takes place. He found
that the muscularis and the mucosa were pushed completely out of the way
when the button was made fast, so that the peritoneum and the submucosa
were the only coats left within the bite of the button (Fig. 13.) It is
difficult to understand how this could happen at once, although the lighter
structure of the mucous membrane would probably soon succumb to the
pressure exerted from the inside. It is also entirely possible that the muscu-
lar fibers may be ruptured by the crushing of the instrument, thus permitting
them to retract out of the grasp of the button. Barbat found that the perito-
neum was so infolded that there was no uncovered surface at anypoint. The
junction of the mesentery with the bowel uncovers a narrow area where the
peritoneum is reflected to pass around the gut. Of course this point could
not be covered by peritoneum under any circumstances. After a period
of from one to three weeks, possibly much longer, the pressure of the button
causes death and sloughing of the bowel edges within its clasp; thus the
button is liberated, and is allowed to pass on. Sections taken at this time
show that healing has occurred between the two peritoneal and the two sub-
mucous layers. The mucosa is lacking over the line of approximation for
a variable distance, usually not more than one-twentieth of an inch. The
internal ulcer, therefore, is much narrower than that which results from
other methods of anastomosis, and, although it might have some advantage
in hastening the closure of the gap, yet it is evident that the reason for the
condition is the extreme thinness of the line of union. The pushing aside
of the muscular layers occasionally makes a narrow scar which, presum-
ably, is not so firmly organized as if it had the additional strength of the
muscular layers. Barbat states that regeneration of the mucous membrane
begins four to six weeks later. If this observation has been correctly under-
stood by me, the time required is from four to six times as long as that used
by the suture in layers.

The final result is a good one : each grows up to the scar, and attaches
itself to the corresponding layer on the other side. In Barbat's specimens
there was no reproduction of the muscularis mucosae (Figs. 14, 15, and
16.)

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Fig. 13.- — Repair Following the Use of the Murphy Button, Three Days.
Shows mucous and muscularis pressed away at point of union. (Drawn from Barbat.

Mucous membrane

Muscularis mucosa?

Circular muscle

Longitudinal muscle

p IG I4i — Repair Following the Use of the Murphy Button, Thirty-six Days.
Firm healing of wound, no repair of muscularis mucosae (Drawn from Barbat.)

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Longitudinal muscle

Fig. 15. — Repair Following the Use of Murphy Button, Forty-two Days.
Thin scar; mucosa attached to what originally was the external callus. Muscle-fibers separated.
No repair of muscularis mucosas. (Drawn from Barbat.)

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scar. (Drawn from Barbat.)

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Fig. 17. — Section Across the Mass of Tissue Enclosed within the Loop of the Elastic

Ligature, Five Days' Duration.
Showing pressure necrosis due to the elastic ligature. (Murphy.)

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Fig. i8. — Section at Right Angles to the Line of Union of the Stomach and Jejunum, Twelve

Days' Duration.

Showing an area of granulation tissue between the two viscera with the mucous membrane growing
over it from either margin. (Murphy.)

HMHHBMMBnSB

"V>*E??,

- 4 -'

-r

.■■-'

^>, RN rV\

;r " + — -7?"

Eg \:*~- '. '/'trs— /A-

, - • '"

■ iltm-nfJej

- r-, , j

|L1 :w formed coti.tis.
;-';4— » " m.jn.

of
Stonta,cb

I :~ ?W%Sk

. ' ■ '",■'-■

Fig. 19. — Section at Right Angles to the Line of Union of the Stomach and Jejunum, Thirty

Days' Duration.
Showing fairly dense scar tissue completely covered by newly formed mucous membrane. A, Point
at which submucosa of jejunum has been cut through; B, point at which submucosa of stomach has
been cut through. (Murphy.)

W'-W- . ■ , ■ ■ ■ •

ttl.m.oiJcj. $!';,

'•>• .

ift.w,. of iii-jft,

^|BrLdcje of
fis con. ti-s.

-iv,';:. :. ' :.' $lil ''/'v: ■

jr IG _ ao _ — Section across an Adhesion, Seven Days' Duration, which had Formed between
the Edges of the Jejunum after the Elastic Ligature had Cut Out. (Murphy.)

' ■■•

& ''■ n

THE REPAIR OF INTESTINAL WOUNDS. 63

REPAIR FOLLOWING THE USE OF THE ELASTIC LIGATURE.

The technic employed in forming an anastomosis by means of the elas-
tic ligature is described in Chapter IV. In brief this technic consists in
sewing together two adjoining hollow viscera with a single rubber suture,
which penetrates into the lumina, and is placed in the long axes of the organs.
When the suture is drawn tight and tied the walls of the bowel or of the
stomach, which it includes, will be constricted. A continued constriction
of the tissues grasped by the rubber will result in necrosis and sloughing,
thus establishing a permanent artificial opening between the two organs.
When the rubber ligature has cut itself free it drops into the intestine and
passes on. As an additional precaution against leakage the peritoneal
surfaces of the attached organs are sewed together around the rubber
ligature, so that cutting through of the ligature will be devoid of danger.

The repair of the intestine after the introduction of the elastic ligature
may be stated as follows:

The tissues included within the grasp of the ligature at once become
anemic, and rapidly degenerate (Fig. 17). The muscle-fibers lose their
staining properties and pressure necrosis with actual rupture of the muscle
ensues. As the degeneration of the ligatured area progresses, a reaction
is noted at the line of demarcation between the living and the dead tissues,
characterized by an infiltration with leucocytes, small round cells, and
serum. After four or five days the tissues have been changed into a slough,
which becomes loosened, and is finally cast off. The conditions now
present are exactly similar to those noted when the bowels are opened at
once with a knife, and sewed together with two layers, — i. e., the edges of
the opening are sealed and held in place by the plastic exudate during the
process of healing of the internal ulcer.

The covering of the internal ulcer with mucous membrane requires
from seven to ten days. Fig. 18 shows the internal ulcer resulting from
the cutting out of the ligature. In this case the mucous membrane may
be seen closing over the ulcer twelve days after operation. It is of interest
to compare this specimen with Fig. 6, which shows almost the same stage
of healing twelve days after an anastomosis with the segmented ring. Fig. 1 9
illustrates the end result where the granulation tissue at the line of anastomo-

64 INTESTINAL AND GASTRIC OPERATIONS.

sis has been changed into a scar, and the suture-margin of the hole com-
pletely covered with mucous membrane.

During the act of the cutting out of the ligature it is possible for different
points on the surface of the internal ulcer to be drawn together. If opposite
points on the edges of the opening are held in apposition sufficiently long,
adhesion will take place between the two raw surfaces, and the bridge thus
formed will divide the stoma into two parts, neither of which will be large
enough to serve the purpose of the operation.

Fig. 20 is a section through a bridge of tissue caused in the manner just
described. It is formed wholly of granulation tissue.

The observations concerning repair following the use of the elastic
ligature are drawn from a study of the specimens and drawings kindly
loaned me for the purpose by Dr. F. T. Murphy. 1

1 Murphy, F. T. Boston Med. and Surg. Journal, January 28, 1904.

SUTURE MATERIALS, NEEDLES, TYING KNOTS, SUTURES, CLAMPS. 65

CHAPTER II.

SUTURE MATERIALS, NEEDLES, TYING KNOTS, SUTURES, AND

CLAMPS.

SUTURE MATERIALS.

To obtain the best results in gastrointestinal surgery, both soluble
and insoluble suture material must be used. It is customary to employ
soluble material for stitches which enter the bowel lumen, while the use
of insoluble material is reserved for the outer seromuscular layer. No fixed
rule, however, can be given, for surgeons have successfully used soluble
sutures for the seromuscular, and insoluble for the penetrating stitches.

The inner layer of stitches is only a temporary affair, the purposes of
which are to approximate the cut edges accurately, to control bleeding, and
to reinforce the outer layer. Therefore, there are no advantages in retain-
ing these stitches after the first few days, when the adhesions and the granu-
lation tissue have already bound the cut bowel ends tightly together.

While the small details of the process of repair inside the bowel may
be disregarded, so long as the serous coats are carefully brought together,
it must be remembered that every stitch which enters the bowel lumen is
subjected to a chance of infection from the organisms within the intestine.

Theoretically, this is a serious danger; but, practically, very few acci-
dents result from this cause. Leakage of a suture may usually be attrib-
uted to one of three causes:

(1) Inaccurate approximation of the peritoneum between the stitches.

(2) Infection from escape of intestinal contents from the opened gut.

(3) Bruising of the cut edges by rough handling during the operation.
If these three errors of technic are avoided, the occasional penetration

of the bowel lumen may be disregarded.

On the whole, catgut fills most of the requirements for the inside stitches.
Either plain or chromicized gut can be used, but the latter is preferable,
merely because its greater strength allows it to be used in small sizes.

66 INTESTINAL AND GASTRIC OPERATIONS.

Chromic gut will resist the disintegrating action of the gastric juice for from
one to three weeks, and the portions of the stitch not thus exposed may-
remain intact for several weeks longer.

The whole theory and practice of intestinal surgery is founded upon
the fact that two peritoneal surfaces, adjoining an intestinal wound, adhere
to each other when held for a certain time in apposition. Twenty-four
hours at least are necessary to seal the joint in this manner. To hold the
tissues during this critical period, and until the process of repair is thoroughly
established, suture material is required which is wholly unchangeable by lo-
cal conditions. Although catgut is not absorbed in twenty-four hours, swell-
ing from absorption of water, and subsequent loosening of the knot under the
influence of distention or of active peristalsis of the bowels, is not uncommon.

The best examples of insoluble material are silk and Pagenstecher's
celloidin linen thread. Silk is still preferred by some for the seromuscular
stitches ; but it makes by no means an ideal suture as it always acts badly
in the neighborhood of an infected focus. The infection of any insoluble
stitch is unfortunate, but the loose texture of silk offers a refuge to pyogenic
cocci, so that the stitch itself becomes a source of contagion.

In comparison with silk, celloidin linen thread has numerous advan-
tages. The hard surface of thread thus prepared is resistant to the pene-
tration of bacteria, and, once thoroughly sterilized by boiling, can be buried
in the abdomen with relatively little danger.

The ease experienced in handling celloidin thread is accounted for by
the fact that it does not lose its hard consistency when soaked with water,
and this prevents it from sticking to the fingers or to the sheets. Cutting
out of a celloidin stitch is a rare occurence, for the irregularities of the
individual strands are converted into a smooth surface by the celloidin.
This is a very useful quality, though it applies more generally to the small
sizes, for in the larger sizes the thread is somewhat rough.

Celloidin thread acts well inside the stomach. The portions exposed
to the action of the gastric juice will be disintegrated in about six weeks ;
the remainder of the stitch will gradually loosen and fray out, until, at the
end of six months, only the deepest portions will be left where they may
remain indefinitely, encapsulated within the tissues. During the process
of erosion by the gastric juice, salts may be deposited upon the thread,

Fig. 2i. — Method or Holding Curved Needle, Point toward Operator.

Fig. 22. — Method of Holding Curved Needle, Point away from Operator.

SUTURE MATERIALS, NEEDLES, TYING KNOTS, SUTURES, CLAMPS. 69

forming concretions which may remain in place for weeks and attain a
diameter of one-eighth inch. This deposit of salts may temporarily retard
the further destruction of the thread, but it has no other effect upon the
repair of the wound.

After repeated boiling, celloidin thread becomes friable and splits
longitudinally, but at least three sterilizations can be done with safety. The
above observations are drawn from a series of animal experiments.

NEEDLES.

A large, round-pointed, straight needle held in the fingers makes sewing
very easy, although many surgeons prefer a curved needle and a needle-
holder. The needle-holder, however, prevents the operator from knowing
exactly how deep he is penetrating into the bowel wall because the delicacy of
touch essential for this demands contact between fingers and needle. A
straight needle will reach practically
any point, but, if occasionally found " ""'

to be awkward, the difficult Stitches FlG - ^--Milliner's Needle No. 3-Actual

' Size.

may be taken with a curved needle.

Moynihan uses a needle with so full a curve that its manipulation is easy

without a holder (Figs 23, 24). In sewing with a
curved needle the point maybe held either towards or
away from the operator, as circumstances require.
When the point is towards the operator, the thumb
is firmly fixed in the bend of the needle, while held
in place by the counter-pressure of the first finger.

Fig. 24. — Moynihan's r J 1

Curved Needle, as Modi- The thread may be caught in the palm, by the

EIED BY SCUDDER-ACTUAL ^ ^^ ^^ ^ ^ ^ ^ ^^ ^ ^ ^^

tional safeguard against slipping of the needle. If

the point is away from the Operator, a reverse

position is taken, the first two fingers being wedged into the curve of

the needle, while the thumb presses firmly from the opposite side

(Figs. 21, 22).

On the whole, the straight needle offers such an increase in speed and
accuracy of penetration that it is usually to be preferred. If a straight
needle is chosen, a No. 3 milliner's, threaded with fine celloidin thread (No.

7°

INTESTINAL AND GASTRIC OPERATIONS.

i) is a serviceable combination. No. o chromic catgut threads easily into
both the No. 3 milliner's and the Moynihan curved needles.

TYING KNOTS.

There are several methods of tying square knots. One good method
should be learned and used exclusively. A satisfactory system, described
below, was shown me by Dr. C. B. Porter.

(1) The long end of the tie is held in the palm of the left hand, the short
end between the thumb and finger of the right hand (Fig. 25).

Fig. 25. — The long end of the tie is held in the palm of the left hand, the short end between the thumb

and finger of the right hand.

(2) The short end, in the right hand, is passed half way around the hemo-
static forceps, where it is caught by the forefinger of the left (Fig. 26).

(3) The short end is brought around to the front again by a turn of the
wrist, and passed over the long end (Fig. 27).

(4) The short end is again grasped by the right to steady it while the
two sides of the loop are held apart by the middle finger of the right and the
forefinger of the left hands, the left forefinger catching the loop at the point
of crossing of the two arms (Fig. 28).

(5) The short end is carried through the loop from beneath upwards,

Fig. 26. — The short end in the right hand is passed half way around the artery forceps, where it is

caught by the forefinger of the left hand.

*fu •'

p 1G 27. Xhe short end is brought around to the front again by a turn of the wrist and passed over

the long end.

Fig. 28. — The short end (S) is again grasped by the right hand to steady it, while the two sides
of the loop are held apart by the middle finger of the right hand and the forefinger of the left hand,
the left forefinger catching the loop at the point of crossing of the two arms.

Fig. 29. — The short end is carried through the loop from beneath upwards, using the thumb as a
shuttle, and the short end again picked up by the right hand.

SUTURE MATERIALS, NEEDLES, TYING KNOTS, SUTURES, CLAMPS. 73

using the thumb as a shuttle, and the short end again picked up by the
right hand (Fig. 29).

(6) The tissues are allowed to relax by removing the artery forceps, as
the first half of the knot is tied over the index fingers. No pull should be

Fig. 30. — The tissues are allowed to relax by removing the hemostatic forceps, and the first half
of the knot is tied over the ends of the index fingers. No pull should be exerted upon the first half of
the knot while the second half is being tied, else slipping will occur.

Fig. 31. — The second half-knot is exactly the reverse of the first. The short end is carried around
the left forefinger from right to left at a point where it will cross the long end of the tie, the palm being
turned down at the same time.

exerted upon the first half of the knot while the second half is being tied,
else slipping will occur (Fig. 30).

(7) The second half of the knot is exactly the reverse of the first. The
short end is carried around the left forefinger from right to left at a point

Fig. 32. — The loop is kept open by the right middle finger, and the left thumb quickly substituted
for the left forefinger, since the latter is to act as the shuttle. The short end is, finally, carried through
the loop by the left forefinger, from above downwards and caught by the right hand.

FlG - 33- — The knot is tightened by pulling down with the left and up with the right hand.

SUTURE MATERIALS, NEEDLES, TYING KNOTS, SUTURES, CLAMPS. 75

where it will cross the long end of the tie, the left palm being turned down-
ward at the same time (Fig. 31).

(8) The loop is kept open by the right middle finger and the left fore-
finger, since the latter is to act as the' shuttle (Fig. 32). The short end is
finally carried through the loop by the left forefinger from above down-
ward and caught by the right hand.

Fig. 34. — Richardson's One-hand Knoi.

The tie has been passed around the snap, the

thumb ready for the first tie.

Fig. 35. — Richardson's One-hand Knot.
Drawing the first turn taut.

(9) The knot is tightened by pulling down with the left, and up with
the right hand (Fig. 33).

Richardson's One-hand Knot. 1 — This method is especially adapted
for tying the first knot of a continuous suture. With it the end of the thread
can be made fast with great rapidity. It requires rather skilful fingers to
tie the knot every time without a miss, for the least slipping of the thread

1 M. H. Richardson, not published.

7 6

INTESTINAL AND GASTRIC OPERATIONS.

will hinder the shuttle action of the fingers. It is common to see several
attempts made in each loop before the whole knot is completed. The
steps taken in tying Richardson's one-hand knot look confusing both on
paper and in the cuts, but the manoeuvre itself is easily understood and
simply done. When the knot is used to tie a bleeding vessel the short end of

Fig. 36. — Richardson's One-hand Knot.
Tying the second half of the knot.

the ligature is passed around the snap from right to left in the same manner
as described for the first step of the preceding knot, where the end is seized
by the left hand. The tie is made with two motions :

(1) The short end is carried over the long end, from left to right, the
left thumb pushing the short end around and under the point of crossing
from below upward until it appears between the two arms of the loop as

SUTURE MATERIALS, NEEDLES, TYING KNOTS, SUTURES, CLAMPS. 77

they are held apart by the left index finger (Fig. 34). The first half-knot
is then set, and, if a snap has been used, it is removed (Fig. 35).

(2) The second half of the knot is the reverse of the first. The short
end is drawn across the long end from right to left and carried under the
point of crossing, using the thumb as a shuttle and the forefinger to hold
apart the loop, just as was done in the first step (Fig. 36). This technic will
produce a square knot every time if the short end is pointed to the right in

Fig. 37. — Seamstress Knot, First Step.
Left hand draws both ends of stitch to left, thus forming a loop. Needle enters loop from below upward

and to right.

the first half, and to the left in the second half. These steps may be re-
versed in order if desired.

Seamstress Knot. — This knot is used by Dr. Oviatt, of Wisconsin,
through whom it came to the author's attention. Its rapidity and accuracy
are gained by substituting the needle for the finger in carrying the end of the
tie through the loop. It is assumed here that the stitch has been taken in a
direction away from the surgeon, thus leaving the short end on the proximal
and the long end on the distal side of the wound.

(1) The long end with the needle is first drawn back across the wound

Fig. 38. — Seamstress Knot, Second Step.
First half of knot tied as follows: Short end pulled away from operator with left hand; long, or needle

end, drawn toward operator with right.

Fig. 39. — Seamstress Knot, Third Step.
Last half of knot. The short thread in left hand is twisted to right to form a loop. Needle enters
loop from above to right. The second half of knot is tied by pulling away with long or needle end,
and toward operator with short end.

SUTURE MATERIALS, NEEDLES, TYING KNOTS, SUTURES, CLAMPS. 79

toward the operator. The point of crossing of the two ends is seized be-
tween the left thumb and forefinger and held up while the needle is pushed
under the arch made by the thread from left to right (Fig. 37).

(2) The first half of the knot is set by pulling downward on the long
or needle end with the right hand, and upward with the short end in the
left hand (Fig. 38).

(3) To tie the second half of the knot the short end in the left hand is
carried back across the wound toward the surgeon

and slightly twisted between the fingers so that a
good loop is furnished. Through this loop the
needle passes from left to right (Fig. 39) . The knot
is set by pulling upward on the long end in the right
and downward on the short end in the left hand.
Surgeon's knot is made in exactly the same
manner as other square knots are made, except
that two turns are taken instead of one in the first
half (Fig. 40). It is employed to prevent the slip-
ping of the first half while the second half of the
knot is being tied. This is a dangerous knot to use
in intestinal work because the double turn in the
first half of the knot prevents the knot from slip-
ping easily in either direction, thus adding an obstacle to setting the
knot which is not compensated by its other qualities. So much traction is
exerted upon the stitch holes in tying the surgeon's knot that the stitch
frequently cuts out during the manoeuvre.

Fig. 40. — A Surgeon's Knot
as it is Usually Tied.

Note that first half of knot
has two turns, while the second
half has but one.

SPECIAL TECHNIC OF SUTURES.

The sutures employed for intestinal anastomosis may be divided into
three classes :

(1) Those that aim to approximate the peritoneal coats and penetrate
only through the muscularis mucosae (seromuscular) :

(1) The Cushing right-angle continuous.

(2) The Lembert continuous, [interrupted].

(3) The mattress (Halsted), (Gould).

(4) The Purse-string.

INTESTINAL AND GASTRIC OPERATIONS.

(2) Those that aim to approximate the cut edges without, necessarially,
bringing together the peritoneal coats.

(1) The through-and-through continuous, or glover's.

(2) The buttonhole (Heister).

(3) Those that penetrate all coats and approximate the peritoneum, —
i. e., penetrating mattress :

(1) Maunsell's mesenteric stitch.

(2) Connell's mattress anastomosis.

(3) Seromuscular-penetrating mattress, (Jobert).

The Seromuscular Stitch. — The
muscularis mucosae is the only portion
of the bowel wall that offers a firm
anchorage for a stitch, and the
recognition of this tough elastic layer
is essential to the security of the
joint. A very good way to become
familiar with the peculiar resistance
offered to the needle, by the mus-
cularis mucosae, is by practising upon
a piece of stretched rubber dam;

the sensations of resistance and penetration are practically identical.

The needle enters the bowel wall at a very obtuse angle (Fig. 41), until

Fig. 41. — The Seromuscular Stitch.

Shows proper angle and depth of penetra^

tion of seromuscular stitch.

Fig. 42. — The Seromuscular Stitch.
Shows method of lifting up fold of bowel before pushing the needle completely through.

it just pierces the muscularis mucosae, when the point is firmly lifted,
and with it the fold of bowel wall which it has impaled. The needle is

SUTURE MATERIALS, NEEDLES, TYING KNOTS, SUTURES, CLAMPS. 8 1

then pushed through the opposite side of the fold (Fig. 42) and the thread
drawn tight. An accurate approximation of the serous surfaces is assisted
by always picking up folds of equal length. The needle should never be
pushed through until the fold is lifted on the needle, as just described.

Fig. 43. — Cushing Right -angle Continuous Stitch.
The first layer of through-and -through stitches has been placed. Note method of introducing the first

stitch and knot of the Cushing suture.

Fig. 44. — Cushing Right -angle Continuous Stitch.
Note wave-like suture line. Stitch half completed.

The Cushing Right-angle Continuous Stitch. 1 — To begin this stitch,
the needle pierces the bowel parallel to the wound, but in a direction opposite
to that of the intended suture (Fig. 43), thence crossing the wound at a

1 Cushing, H. W. Med. and Surg. Reports, Boston City Hospital, 1889

INTESTINAL AND GASTRIC OPERATIONS.

right angle it pierces the bowel again exactly opposite, and parallel to the first
half of the stitch, this time in the direction of the intended suture. This places
the knot conveniently for continuing the suture. The subsequent stitches
are taken parallel with the wound, about one-eighth inch apart. The

Fig. 45. — Cushing Right-angle Continuous Stitch.

Note method of depressing the first layer of stitches with needle. To tighten the stitch the thread is

drawn out exactly in the direction of the last stitch taken, parallel to the wound.

Fig. 46. — Cushing Right -angle Continuous Stitch.
Suture completed. Note method of tying last knot by drawing tight both arms of loop with fingers.

thread crosses the wound at right angles, and, leaving about one-eighth
inch margin from the cut edge, again enters the peritoneum parallel to the
wound, at a point opposite the hole of exit of the last stitch (Fig. 44). After

SUTURE MATERIALS, NEEDLES, TYING KNOTS, SUTURES, CLAMPS. 83

each stitch the thread should be drawn tight, and, to prevent cutting out,
the pull should be made parallel to the wound, exactly in the direction of
the last stitch taken. In order to bring the serous surfaces closely together
when the stitch is tightened, the first layer of through-and-through sutures
should be pushed down with the needle while the thread is pulled with the
other hand (Fig. 45). When this continuous stitch has been properly
placed and tightened, the thread, which is completely buried by the invag-
inated serous surfaces, travels parallel to the wound in nearly a straight
line, and a wave-like suture line results which is caused by the dovetailing
of the individual needle bites.

After the last stitch has been placed the thread is picked up at the point
of its last crossing, between the exit of the next to the last and the entrance
of the last stitch. The thread is pulled out here in a loop, long enough for
convenient tying, and knotted with the single thread which has just emerged
from the hole of exit of the last stitch. Both arms of the loop must be
separately pulled tight to set the knot (Fig. 46).

The Lembert Stitch 1 is used both for continuous and for interrupted

Fig. 47. — The Lembert Stitch.
The interrupted stitch is shown on the left, the continuous stitch on the right. The apparent irregu-
larity in the continuous stitch is due to its not yet having been pulled tight.

sutures. The stitches are placed at a right angle to the line of the wound,
about one-eighth inch from the cut peritoneal edge (Fig. 47), and when
tied, roll in the edges, and perfectly approximate the serous surfaces. If
the suture is to be a continuous one" the manoeuvres are exactly the

1 Lembert. Repertoire Generate d'Anatomie et de Physiologie Pathologique, T. u, p. 3, 1826.

2 Dupuytren, Diffenbach, Lehrbuch der Chirurgie, Bd. m, S. 458.

INTESTINAL AND GASTRIC OPERATIONS.

same as observed for the interrupted stitch, although, instead of tying
separately, all the stitches are connected with each other. After placing
the first stitch, the thread is carried diagonally across the wound to the
new stitch, which enters the bowel a short distance further along, parallel
with the first. The last knot is tied in the same manner as done in the
right-angle continuous stitch of dishing. Figs. 48 and 49 show the stitches
in cross section.

Fig. 48. — Lesibeet Interrupted Stitch, with Fig. 49. — Leubert Continuous Stitch

Cross Section. with Cross Section.

Fig. 50. — Halsted Mattress Stitch.
A drawn to A.

The Mattress Stitch.— Halsted 1 has described an interrupted mat-
tress stitch for approximating the serous coats (Fig. 50). This suture
consists of two parallel Lembert stitches connected on one side of the wound
by a loop, leaving the two ends free on the opposite side. When these ends
are tied, the lips of the wound are drawn together and a strong, accurate
joint thus obtained. This stitch has the disadvantage of not rolling in the
peritoneum, as well as limiting the extent to which the inversion of the cut
edge may be carried.

1 Halsted, W. S. Johns Hopkins Hospital Bulletin, January 1891.

SUTURE MATERIALS, NEEDLES, TYING KNOTS, SUTURES, CLAMPS. 85

Author's 4 reversed mattress stitch is a modification of the Halsted
mattress. The aim of this stitch is actually to obtain the inverting effect of
the Lembert stitch combined with the added strength of the mattress stitch.
This result is obtained by reversing the loop so that it lies close to the wound.

Fig. 51. — Author's Mattress Stitch.
Note that the loop is reversed. This results in the rolling in of the peritoneum on the side of the

loop — B drawn to A.

The stitch can be remembered by recalling the fact that the first two bites are
taken towards the wound, the second two bites away from the wound (Fig. 51).

Figs. 52 and 53 are cross sections which show well the results
given by the two mattress stitches.

The reversed mattress stitch has one
of its chief uses in burying the stump of an
appendix. The preliminary steps of the
operation are not of importance here.
The meso-appendix is ligated in the usual
way, thus freeing the appendix so that it
can be held forward. A reversed mat-
tress stitch is introduced on the caecum,
the arms of the stitch being placed so that
the base of the appendix lies between

them. A strip of gauze should be passed about the appendix to protect
the mattress stitch from being infected while the resection is being done.
After cleaning the stump of the appendix, the ends of the mattress stitch
are drawn tight and tied, and the stump of the appendix disappears with-
out tucking (Figs. 54 and 55).

1 Gould, A. H. Boston Medical and Surgical Journal, December 29, 1904.

Fig. 52. — Halsted Mattress Stitch, with
Cross Section.

INTESTINAL AND GASTRIC OPERATIONS.

The Purse-string. — This suture is useful in several situations: (i)
In closing the end of a cut intestine to form a blind sac ; (2) as a preliminary

step to the introduction of
mechanical devices ; (3) when-
ever it is necessary to invaginate
an isolated portion of the peri-
toneum, — e. g., to close a de-
nuded area, or to bury the
stump of an appendix. It is
used both in end-to-end and
in lateral anastomoses.

Two methods are quite
generally in use for applying
the purse-string, which differ from each other in their relation to the cut
edges of the opening which they are to close :

Fig. 53. — Author's Mattress Stitch, with Cross
Section.

mm&y^

Figs. 54, 55. — Use of Reversed Mattress Stitch for Burying Stump of Appendix.

(1) The first method 1 is shown in outline and in cross section, respect-
ively, by Figs. 56 and 57. It consists of a series of interrupted seromuscular

1 Doyen. Chirurgen Congress Verhandl., 1898, p. 200.

SUTURE MATERIALS, NEEDLES, TYING KNOTS, SUTURES, CLAMPS. 87

Fig. 56. — The Purse-string Suture.
A series of interrupted stitches placed in continu-
ity. It circles the bowel' about one-eighth inch from
the cut edge.

stitches placed in continuity. This suture, though located about one-
eighth inch from the cut edge of the gut, does not cross the edge, as is done by
the next method. For this reason
it is possible to place the stitch
before opening the bowel, — a de-
cided advantage in providing
against sepsis. The needle en-
ters the anti-mesenteric border of
the bowel and circles the gut, or,
in lateral anastomosis, the pro-
posed line of incision, with fre-
quent bites. When it reaches the
mesenteric border, it crosses un-
der the mesenteric attachment,
appearing on the other side, after
which it passes up to the point of
beginning on the anti-mesenteric
edge. A half-knot is tied in the two ends in order to allow the suture
to be made fast as soon as possible after opening the intestine. Fig. 58
illustrates, somewhat diagrammatically, the use of the purse-string for

lateral anastomosis 1 . The dotted
line which appears on the cut edges
of the incision indicates the path of
the stitch through the tissues; it is,
in fact, exactly like other seromus-
cular stitches . In placing the purse-
string for lateral anastomosis it
should be held in mind that the in-
cision into the side of the intestine
will be a straight line, so that the
purse-string must not inclose a cir-
cular area, but must be made in
two halves, each consisting of several bites forming a straight line parallel
to the future incision. These halves are connected at one end by a loop,

Fig. 57. — Purse-string Stitch, Cross Section.

1 Murphy, J. B. New York Medical Record, Vol. xlii, 1892, December 10, p. 667.

INTESTINAL AND GASTRIC OPERATIONS.

as shown in Fig. 58, and some care will be needed to avoid cutting the
thread when the opening is made.

Fig. 58. — Purse-string Suture for Lateral Anastomosis.
Dotted lines on cut edge show depth of penetration of stitches; not an actual cross section.

Fig. 59. — Murphy's Purse-string Suture, U SED for Button.

A continuous suture around the cut edge of the bowel, including the mesentery. (Redrawn from

Bickham.)

(2) The second method is used by Murphy 2 in the introduction of his
button. In this instance the suture begins also at the anti-mesenteric'bor-

2 Murphy, J. B. Ibid., p. 672.

SUTURE MATERIALS, NEEDLES, TYING KNOTS, SUTURES, CLAMPS. 89

der, but is placed after the bowel has been opened. It pierces directly
through all the bowel coats and travels around the cut edges over and over,
from without inwards. When the mesenteric attachment is reached the
stitch skips diagonally across the triangular section of mesenteric fat that
marks the junction of the bowel with its mesentery, and picks up a portion
of the mesentery at that point. The suture finally completes the circuit
of the second half of the circumference, ending at the free border, beside
the hrst hole of entrance of the needle (Fig. 59). This method of placing
a purse-string is very effective mechanically, but the constant handling of
the open bowel soils the fingers and adds unnecessarily to the danger of
infection.

The Through- and -through Continuous Suture (Glover's) 1 .—
Formerly it was considered necessary to
sew the bowels together by layers before
approximating the serous surfaces. By
this arrangement, one layer of stitches was
used for the mucous membrane and another
for the muscle, and a third for the peri-
toneum. As shown in the study of the
process of repair, the healing of the cut
edges forming the internal ulcer is not ^

' Pig. 00. — Glover's Continuous Stitch,

accelerated by an inner layer of stitches, with Cross Section.

but rather retarded owing to the necessity

of absorbing these stitches before the ends can wholly heal over. While
it is not necessary to sew each layer separately, an inner layer of stitches
has sufficient advantages to offset this slight delay in the process of repair.
As mentioned later in considering the end-to-end anastomosis, they serve
to control hemorrhage from the cut edges, and reinforce the seromuscular
stitches while the exudation is taking place which is to seal the joint.

The glover's is a continuous over-and-over suture. The stitch may
start from the inside, or from the outside, according to circumstances; but
its chief feature lies in its penetration of all the coats, including the peritoneal.
It passes from without inwards, on one side, and from within outwards on
the other side (Fig. 60). After penetrating both edges at a right angle, it

1 Salicetto, Guglielmo di. Vulnus Intestini, sutura pellionum, Chirurgia, Venet., 1470, p. 376.

9°

INTESTINAL AND GASTRIC OPERATIONS.

crosses diagonally over the cut edges and again penetrates the opposite
edge. In piercing the bowel wall, the needle should always be placed at a
right angle both to the long axis and to the cut edge of the bowel.

The Buttonhole Suture (Heister 1 ). — This is a modification of the

Fio. 61. — The Buttonhole Stitch, with Cross Section.

glover's stitch and is used to supply tlie place of the latter. The needle
penetrates the bowel edges exactly as in the glover's; but, before crossing,
a half-hitch is taken in the loop. This stitch is useful to approximate
wounds where the tissues cannot relax, such as the skin, where hemorrhage

Fig. 62. — Buttonhole Stitch Doubled. (W. J. Mayo.)

is not important ; but it is unreliable as an inner suture for intestinal wounds
(unless reinforced, as done by W. J. Mayo). It converts the continuous
stitch into a series of interrupted stitches, none of which are tied, so that
the hemorrhage from the spaces between loops is not controlled. If the

1 Heister, Lorenz. Chirurgie, Nurnberg, 1763, Chapter VI.

SUTURE MATERIALS, NEEDLES, TYING KNOTS, SUTURES, CLAMPS. 9 1

stitch is applied while clamps are in place, there is nothing to prevent the
flexible intestinal walls from relaxing when the clamps are removed, thus
loosening the whole stitch. If the stitch is placed without clamps, to be
effective it must be drawn so tight that the cut edges are drawn into irregu-
lar puckerings which render difficult the placing of the seromuscular stitch
(Fig. 61).

The Through-and-through Mattress Suture (Connelly is used for
end-to-end and for lateral anastomosis. This stitch starts inside the lumen
of one bowel, about one-eighth inch from the cut edge. It pierces all the
bowel coats, and, crossing outside the wound, at a right angle, pierces all
the coats of the second cut bowel from without inward, at a spot opposite
and symmetrical to the needle hole in the first cut edge, thus entering the
second bowel lumen. The needle now turns and escapes from the
bowel by again piercing all lay-
ers, from within outward, about
one-eighth inch to one side of the
hole where it entered the lumen.
It then crosses the bowel edges
parallel to the first half of the stitch,
and finally penetrating all coats Fig. 6 3 .-penetrating mattress Stitch, cross

Section of One-hale of Stitch.

of the first bowel, reenters the

lumen. The two ends are tied, as they lie side by side, on the same
lip of the wound, and the serous surfaces thus brought into firm
apposition. A complete anastomosis may be made in this manner
which does not require further reinforcing. These stitches must be
placed close together because there is nothing to control the bleeding from
the intervening cut edge (Fig. 63).

The Mattress Mesenteric Stitch (Maunsell). 2 — The mattress stitch
has its most useful application in establishing a firm joint at the mesenteric
border. The stitch is placed exactly in the same manner as the one last
described. Since the mesenteric attachment is immediately below the
point where the needle will emerge in piercing all coats, the needle enters

1 Connell, M. E. Med. Record, 1892, Vol. xm, p. 335. Connell, F. G. Philadelphia
Monthly Med. Journal, Vol. 1, 1899.

2 Maunsell. Lancet, 1892, Vol. 11, p. 473; American Jour. Med. Sci., March, 1892.

9 2

INTESTINAL AND GASTRIC OPERATIONS.

the triangular mesenteric space for about one-eighth inch (Fig. 64),
then, turning to one side, pierces the peritoneum. Figs. 65 and 66 show
the space for the mesenteric attachment of the intestine. In entering
the second bowel, the reverse plan is necessary, the needle first piercing the
triangular space of the mesenteric attachment before it enters the bowel.
Once inside, the needle turns and passes out again, repeating the steps, and
reenters the first bowel, where it is tied. This stitch should be employed
in every form of end-to-end anastomosis, except the Murphy button.

Fig. 64. — Maunsell's Mattress Mesenteric Stitch.

The Seromuscular Penetrating Mattress ( Jober^-Senn 2 ) . — In
closing small perforating wounds of the intestine, it is difficult to control
hemorrhage, and approximate the peritoneum with the same stitch. Jobert
has described a stitch which serves this purpose with success. It is a
combination of the perforating mattress with the seromuscular stitch. The
stitch begins on one lip of the wound, like the Lembert, reaching down
only into the muscularis mucosae. It then crosses the hole and penetrates

1 Jobert. Archiv. geneYales de Medicine, 1824.
Senn. Intestinal Surgery, 1889, p. 168.

3 "'

CT 1
O

-"c. c '^^

f5-

SUTURE MATERIALS, NEEDLES, TYING KNOTS, SUTURES, CLAMPS. 95

all coats of the opposite lip, entering the bowel lumen. From this point
the stitch again escapes from the bowel, through all coats, ending as a
Lembert, on the first lip of the wound (Fig. 67). Upon tying this stitch the
edges of the wound are rolled in and the bleeding stopped by compression.
Fig. 68 shows the stitch in cross section.

It is generally felt by surgeons that the presence of knots on the per-
itoneal surface of the intestine is a frequent cause of adhesions. This
circumstance has been emphasized in the writings of Halsted and of Con-

Fig. 67. — Seromuscular Penetrating Mattress.
Cross section, showing stitch loosely introduced.

nell, and the suggestion made that the outside knots be done away with
as far as possible. It is difficult, however, to show exactly how much
irritation is caused by the knots, because the bruising of the peritoneum
near the suture may lead, of itself, to the formation of adhesions. As far
as personal experimental work goes, there seems to be more danger of
adhesion formation from rough handling of the peritoneum than from
outside knots.

The comparative value of the interrupted and the continuous stitches
is another mooted question. For the interrupted stitch it may be said that
it never can constrict the lumen, because each stitch pulls parallel to the

Q>6 INTESTINAL AND GASTRIC OPERATIONS.

long axis of the bowel. An excessive edge may, however, be turned in by
successive layers of stitches and thus narrow the intestine ; but this accident
can also occur after use of a continuous stitch. The giving way of a single
stitch during the early hours of healing is not necessarily disastrous if two
layers of sutures are employed, as the remainder of the circumference is
unaffected by the giving way of one stitch, and the inner layer will probably
protect the small gap left by the deficient stitch. If the seromuscular
stitches are properly placed so as to include the muscularis mucosae, and
are made as narrow as compatible with good anchorage, the danger of slip-

Fig. 68. — Seromuscular Penetrating Mattress.
Showing stitch pulled tight.

ping will be reduced to a minimum. Leakage of intestinal contents between
interrupted stitches is not to be anticipated, for the first step of the process
of repair is the rapid distention of the inturned edges with edema and with
blood. The swollen edges at once plug all openings, and the greater the
pressure within the intestine, the more effective is this valve action of the
swollen edges. After twenty-four hours enough exudate has oozed into the
tissues about the joint to glue together the peritoneal surfaces and thus
remove further danger of leakage.

Horsley 1 feels certain that a continuous stitch is superior to a series of

1 Horsley, J. S. Annals of Surgery, 1903, p. 741.

SUTURE MATERIALS, NEEDLES, TYING KNOTS, SUTURES, CLAMPS. 97

interrupted stitches, because, by acting as a splint, it supports the joint,
while at the same time it completely seals in the line of union. It is true
that rest is essential to repair, and it is reasonable to suppose that the imme-
diate approximation obtained with a continuous stitch is more perfect and
tight than that given by interrupted stitches. This view, however, loses its
importance when a comparison is made between joints done, the one with
a continuous, the other with two layers of stitches. The inner stitch is
always a continuous one, and provides the splint action accredited to the
continuous stitch, whatever type of outside stitch is employed. A fair dis-
tinction might be made between the interrupted mattress anastomosis of Con-
nell and one of the methods which employs a single continuous seromuscular
stitch. It will be recalled that the mattress anastomosis is accomplished
entirely by means of interrupted mattress stitches which penetrate all the
bowel coats. It is the aim of the method to place the stitches very near to
the cut edges, so that the edges will be inverted as little as possible. Theo-
retically there would be danger of leakage between the stitches, but prac-
tically it has proved a very safe and strong method. Although I have no
specimens to show it, there is every reason to believe that the cut edges
sweU up and block the interstices between the stitches in the same way that
they were observed to act with the suture in two layers, and with one layer
with the segmented ring. Horsley's experiments, to show that adhesion
between serous surfaces does not necessarially follow their continuous and
close apposition, did not take into account the effect of the cut edges in
pouring out serum into all parts of the joint. It was shown in the ring
series that the inflammatory reaction began at the cut edges at once. As a
matter of fact, it is the accepted opinion that the surgeon should never
subject his stitches to the dangers of distention and increased peristalsis.
This is avoided by dividing the operation into two stages whenever disten-
tion is found. The usual routine is to resect and drain at the first sitting,
followed by suture several days later, after the intestines have been given a
sufficient rest. It is probably just as dangerous to submit a continuous
suture to the test of distention and of violent peristalsis as it is the suture
in two layers, the outer of which is interrupted.

For the continuous stitch it may be said that it is more rapid than the
interrupted method, need never be drawn into a purse-string, if occasionally

98 INTESTINAL AND GASTRIC OPERATIONS.

interrupted with knots, and leaves a smooth surface at the outside joint
angle. The ultimate scar formation is supposedly less dangerous after the
interrupted suture; but this question is so involved with the width of the
inturned edge that no general statement can be made. Both continuous
and interrupted stitches are perfectly efficient if correctly placed, and
can be substituted for each other to fit the circumstances.

CLAMPS.

Intestinal Clamps. — There are several methods of controlling leakage
of contents during the suture of an opened viscus. For intestinal operations
it was formerly found sufficient for the assistant to pinch the bowel with the
fingers, but this method removed the assistant from further participation
in the operation, while demanding of him the utmost care to avoid relaxation
of the fingers, which the fatiguing nature of the position made it difficult
to carry out.

The next step in the evolution of the technic of leakage-control was the
constriction of the gut lumen by means of a silk tie, or a piece of gauze.
This method, although freeing the hands of the assistant, is inferior to
simple finger-compression since it requires the perforation of the mesentery
at its junction with the bowel. The terminal branches of the third vascular
arch, which is nearest the intestine, travel at a right angle to the long axis
of the bowel (Fig. 79), and, theoretically, might not be injured by placing
a ligature about the bowel if the mesenteric incision avoided these vessels.
On the contrary, the close relation of these terminal branches to each other
makes it really difficult to avoid them, especially if the mesentery be opaque
with fat. Just how much damage is done by wounding the small vessels
placed at the mesenteric border would be hard to determine, but, on general
principles, it is safer to preserve the entire blood supply of an organ when
possible.

The adaptation of clamps has proved of great value to gastro-intestinal
surgery, and has superseded both of the crude measures just mentioned.
It is one of the rare situations in which special instruments are serviceable
in intestinal work.

The simplest method of compressing the intestines is by means of the
straight circumcision clamp (Fig. 69). A clamp similar to this has been

SUTURE MATERIALS, NEEDLES, TYING KNOTS, SUTURES, CLAMPS. 99

devised by Murphy, the blades of which are bent at a right angle to the
spring handle. This adds very little to the value of the instrument, while,
on the contrary, the circumcision clamps are much more readily obtained.
As expedients to prevent the tissues from slipping through the blades, the
latter are furnished with fenestras and with teeth. These may prove useful
additions to the plain blade in the operation of circumcision, but they have
no place in intestinal work, because the circumcision clamp is only used
in end-to-end sutures of the intestines where the clamp is placed so far
from the cut edges as to render the

question of slipping of no impor- feaa««^<!!* ..^/ jfeshaifr
tance. However, the clamps about Fiq 69 _ Steaight C ircumc ISI on Clamp
to be described are used both for for Intestine.

• , ,• 1 1 r , ■ ,■ Length of blade, 2I inches; width of blade

intestinal and for gastric operations, |inch . length of handle , 3 inches .

where a tight grasp of the fold is

essential. The jaws of all clamps which are used merely to compress the
intestine or the stomach should be covered with rubber tubing in order to
interpose a cushion between the intestine and the hard surface of the
instrument. Attention should be called to the proper size of tubing to be
chosen for this work, because in lateral anastomosis, and in all stomach
operations, the size of the rubber tubing is the key to the success of the
clamp. Generally speaking, if the tubing is of a caliber which admits its
being easily slipped over the blade of the clamp, no compression which it is

safe to apply to the included intestine or stomach

ns^ffiassa^ssssaa will prevent the tubing from rotating around the

„, TT1!TM „ blade, under the influence of the drag of the

Fig. 70. — Rubber Tubing '

for intestinal and Small tissues. It seems obvious that the addition of
stomach clamps. - ^ windows to prevent the rubber

Diameter about T \ inch. 1

from turning is a wrong principle. The tubing
should be so small that it requires stretching to draw it over the blade.
The lubrication of the rubber with lysol will make the procedure compar-
atively easy. In the author's clamps, described later, there are two
narrow grooves which run lengthwise on the inside of the blades, but it is
probable that their presence is of no additional value to the clamp. Fig. 70
shows the correct size of tubing for gastroenterostomy and for intestinal
clamps.

IOO

INTESTINAL AND GASTRIC OPERATIONS.

For clamping the intestine any of the smaller stomach clamps are
serviceable. Krause's clamp is very good on account of the full curve of
the blade which allows the handle to be tucked away from the field of
operation. This clamp is described below. In the days when intestinal
clamps were not boiled as a routine in all abdominal
layouts various contrivances came into vogue as make-
shifts in emergencies. Although it would seem that the
assistant's fingers are superior in every way to instruments
which penetrate the mesentery, yet the methods of Pean
and of Maylard are so ingenious that drawings have
been made from Binnie's Surgery to illustrate their
technic. Figs. 71 and 72 are self-explanatory.

Gastric Clamps. — For gastroenterostomy and all
stomach operations except the larger resections, a small
clamp is desirable. Fig. 73 shows Krause's clamp which
has been previously mentioned. The special character-
istics of this clamp are its thin, flat blades, the curve of
which is much fuller than that of the other small clamps.
It is claimed that in difficult operations upon the pylorus
and the first portion of the duodenum the bend in the
blades is very useful as an aid in getting a good bite of
the intestine when it is necessary to work in a deep hole.
Figs. 74 and 76 illustrate the author's modification of
the Doyen clamp. It is a slight instrument with nar-
rower, lfess fully curved blades than the Krause clamp,
while the handles are longer. This clamp was designed
for use in gastroenterostomy. The actual dimensions of
this and all other clamps included in this description are
given with the cuts.

There are occasional cases where a straight clamp
is of use. Fig. 75 represents Scudder's straight clamp. The blades are
toothed and fenestrated. This clamp and Moynihan's straight clamp
resemble each other in that both have straight fenestrated blades of about
the same length.

In extensive resections of the stomach long, heavy clamps are re-

Fig. 71. — May-
lard's Method of
Using Forceps for
Intestinal Clamps.
(Drawn from Bin-
nie.)

Fig. 72. — Pean's Method of Using Hemostatic Forceps and Rubber Tube in Place of

Clamp. (Drawn from Binnie.)

,r o\

SUTURE MATERIALS, NEEDLES, TYING KNOTS, SUTURES, CLAMPS. 1 03

Fig. 73. — Kratjse's Stomach Clamp.
Length of blade, five inches; width of blade, \ inch; curve of blade, J inch; length of handle, 4J

inches.

Fig. 74. — Author's Stomach Clamp.
Two views. Length of blade, 5 J inches; width of blade, \ inch; curve of blade, \ inch; length of

handle, 4! inches.

Fig. 75. — Sctjdder's Straight Stomach Clamp.
Length of blade, 5^ inches; width of blade, \ inch; length of handle, 4J inches.

io4

INTESTINAL AND GASTRIC OPERATIONS.

quired. Harrington has devised two clamps, one with curved, the other
with straight blades, which he uses in all stomach operations. The blades,
made without teeth or corrugations, are longer and heavier than the usual

Fig. 76. — Author's Stomach Clamp.
Compare in size with Figs. 77, 78.

gastroenterostomy clamps. This clamp is specially adapted for resections
of the middle portion of the stomach. Fig. 77 is a cut of Harrington's

Fig. 77. — Harrington's Straight Stomach Clamp.

Length of blade, 8 inches; width of blade, j\- inch; length of handle, 4! inches.

Fig. 78. — Kocher's Crushing Clamp.

Length of blade, 7} inches; width of blade, f inch ; curve of blade, J inch ; length of handle, 6g inches.

straight clamp which is used in Figs. 180 and 181 in the technic of resect-
ing the middle portion of the stomach.

One of the very valuable stomach clamps is Kocher's so-called crush-
ing clamp (Fig. 78). The blades of this clamp are very heavy and strong,

SUTURE MATERIALS, NEEDLES, TYING KNOTS, SUTURES, CLAMPS. 105

while their curve is pronounced. The ends of the blades can be fastened
by a small lever, thus preventing the end of the blades from spreading, as
they are tightened on the fold of stomach. Kocher, in his well-known
technic, uses his instrument to crush the stomach before resecting, but the
clamp is also very reliable for pylorectomy when crushing is not desired.
When employed for crushing, the blades are bare, but for merely obtaining
a secure grasp of the tissues a tight-fitting rubber cover is applied. (The
clamps used for these illustrations were made by Codman & Shurtleff, of
Boston.)

CHAPTER III.
THE ANATOMY OF THE INTESTINES.

The general relationship of anatomy to the various pathological proc-
esses which are found within the abdomen is not considered here. There
are, however, three anatomical subjects which bear directly upon the tech-
nical descriptions to be given later. These subjects are the following:

(i) The blood supply of the intestine.

(2) The lymphatics of the intestine.

(3) Intestinal localization.

THE BLOOD SUPPLY OF THE INTESTINES.

The blood supply of the intestines is derived from the superior
mesenteric and from the inferior mesenteric arteries. The superior mesen-
teric artery supplies the whole length of the small intestine, except the first
part of the duodenum, which is supplied by the pyloric and the pancreatico-
duodenal branches of the hepatic. The superior mesenteric also supplies
the cecum, the ascending, and the transverse colon. The descending
colon and the sigmoid flexure, as well as the greater part of the rectum,
are supplied by the inferior mesenteric artery.

The Blood Supply of the Small Intestine. — The intestinal arteries
which arise from the main trunk of the superior mesenteric "consist of two
groups : the larger number from ten to twelve branches, and arise from the
large primary arch of the superior mesenteric artery; the smaller, from
eight to twelve in number, arise from the terminal portion of the superior
mesenteric. These branches pass between the two layers of the mesentery,
the large branches traversing a distance of 7-8 cm., the small 3-5 cm., after
which they bifurcate. The branches arising from the bifurcation anasto-
mose with the neighboring intestinal arteries, and form, in this manner, a
first series of arches, the convexity of which is turned toward the intestine.
From these arches, new branches arise, to the number of forty or fifty,
which run parallel to each other until they bifurcate. The branches,

106

Fig. 79. — The Blood-vessels of the Mesentery of the Small Intestine.
Drawn from an actual dissection. One layer of the mesentery has been removed, exposing the
vessels. The layer of mesentery remaining forms the background for the vessels. Note the anasto-
mosis of the branches of the superior mesenteric artery, to form arches. In this specimen there are
three series of arches. The vasa recta arise at a distance from the intestinal border, alternating as to
the side of the intestine which they supply.

107

THE ANATOMY OF THE INTESTINES. I09

arising from the bifurcation, anastomose in their turn, thus resulting in a
second series of arches placed nearer to the mesenteric border of the intes-
tine. The small vessels which take their origin from the second series of
arches anastomose again to form a third series of arches, from which arise
the terminal branches, which are distributed to the walls of the intestine"
(Fig. 79). (Poirier and Charpy. 1 )

As a continuation of the above statements by Poirier and Charpy the
following is quoted from the report of Monks/ who has examined a large
number of specimens for the purpose of making clear the vascular anatomy
of the mesentery of the small intestine. Previous work has been done on
this subject by Professor Dwight, 3 of Harvard :

"Opposite the upper part of the bowel the mesenteric vessels are dis-
tinctly larger than opposite any other part of it. These vessels grow smaller
and smaller as we pass downwards until the lower third of the gut is reached,
where they remain about the same size as far as the ileocecal valve. The
arrangement of the mesenteric vessels has some features which intimately
concern the subject in hand (intestinal localization), and which I shall
describe with some detail. Diagrammatically speaking, the main branches
of the superior mesenteric artery unite with each other by means of loops
which are called, for convenience, ' primary loops ;' in some parts of the tube,
'secondary loops;' and even occasionally 'tertiary loops' are superimposed
upon these. From these loops little straight vessels — the vasa recta already
referred to — run to the bowel,, upon which they ramify, alternating, as a
rule, as to the side of the intestine which they supply. The mesenteric
veins are arranged in a manner somewhat similar to the arteries. Opposite
the upper part of the bowel there are only primary loops. Occasionally a
secondary loop appears, but it is small and insignificant as compared with
the primary loops, which are large and quite regular. As we proceed
down the bowel secondary loops become more numerous, larger, and
approach nearer to the bowel than the primary loops in the upper part.
As a rule, secondary loops become a prominent feature at about the fourth
foot. As we continue farther downward the secondary loops (and, pos-
sibly, tertiary loops) become still more numerous and the primary loops

1 Poirier et Charpy. Traite d'Anatomie Humaine, T. 11, p. 771.

2 Monks, G. H. Trans. Am. Surg. Asso., 1903.

3 Dwight, T. Proc. Asso. Amer. Anatomists, 1897, Washington, 1898, x, 79-81.

HO INTESTINAL AND GASTRIC OPERATIONS.

smaller, the loops all the time getting nearer and nearer to the gut. Op-
posite the lower part of the gut the loops generally lose their characteristic
appearance, and are represented by a complicated network. Opposite
the upper part of the intestine the vasa recta are from three to five centi-
meters long, when the loop of small intestine to which they run is lifted
up so as to put them gently on the stretch. They are straight, large, and
regular, and rarely give off branches in the mesentery. In the lower third
they are very short, being generally less than one centimeter in length.
Here they are less straight, smaller, less regular, and have frequent branches
in the mesentery."

The Blood Supply of the Large Intestine. — The blood supply of the
large intestine has no special surgical features which require a detailed
description. The cecum, the ascending and the transverse colon are sup-
plied by branches of the superior mesenteric artery, — i. e., the ileocolic,
the colica dextra, and the colica media. The descending colon and the
sigmoid flexure are supplied by branches of the inferior mesenteric artery,
— i. e., by the colica sinistra and the sigmoid arteries, — while the rectum is
supplied by the three hemorrhoidal arteries which arise from the inferior
mesenteric, the internal iliac, and the internal pudic arteries.

The arrangement of the blood-vessels of the large intestine has its nearest
approach to that of the small intestine in those portions most commonly
affected with surgical disease. New growths of the large intestine (ex-
cepting the rectum) are usually situated either in the sigmoid, the transverse
colon, or the cecum, where the movability of the gut allows a relatively easy
approach to the vessels.

The colica media artery derives additional importance from its relation-
ship with the gastrocolic omentum, where it may be wounded in operations
upon the stomach. The colica media artery inosculates on either side
with the colica dextra and the colica sinistra. The large primary arches
formed in this manner are plainly exposed when the great omentum is
reflected upwards. When the lesser peritoneal cavity is opened during
the operation of posterior gastroenterostomy, a bloodless spot is chosen
under the sweep of the primary arch as it runs to the left to join the
colica sinistra artery.

THE ANATOMY OF THE INTESTINES. Ill

THE LYMPHATICS OF THE INTESTINES.

The following anatomical description is quoted practically verbatim
from Poirier, Delamere, and Cuneo: 1

"The Lymphatics of the Large Intestine. — Lymphatics of the Mo-
pelvic Colon. — The lymphatics of the iliopelvic colon (sigmoid flexure) at
first traverse some small glands which are attached to the terminal branches
given off by the paraintestinal arch and formed by the anastomosis of the
three sigmoid arteries. They then terminate in glands placed over the
inferior mesenteric artery.

"Lymphatics of the Descending Colon. — The lymphatic vessels of the
descending colon present a somewhat similar arrangement to that of the
iliopelvic colon. We need only note the poorly developed glandular appa-
ratus attached to this part of the large intestine.

"Lymphatics of the Transverse Colon. — The lymphatic apparatus
of the transverse colon is much more developed. The juxtaintestinal
glands (between the arch of the colica media artery and the intestinal border)
are here numerous, especially in the neighborhood of the two extremities
of the transverse colon. Further, one almost constantly finds one or two
glands situated in the angle of the bifurcation of the middle colic as well
as two or three others placed along the trunk of this artery. The trunks
coming from the latter pass into the glands of the superior mesenteric chain.

"The lymphatics of the transverse colon communicate to a large extent
with those of the great omentum, so that they are brought into relation
with the lymphatics of the inferior border of the stomach.

"Lymphatics of the Ascending Colon. — The collecting trunks emanat-
ing from the ascending colon at first traverse some few juxtaintestinal
glands; they then meet a gland which is, however, inconstant, placed on
the course of the ascending colic artery, and finally terminate in the glands
of the superior mesenteric chain.

"Lymphatics of the Cecum and Appendix. — The lymphatics of the
cecum and appendix are much more developed than those of other segments
of the large intestine. This is especially true in the case of the appendix,
the lymphoid tissue of which is well known to be abundant.

"The ceco-appendicular collecting trunks follow pretty closely the
course of the blood-vessels. This fact will enable us to divide them into
three groups : the anterior cecal, the posterior cecal, and the appendicular
trunks, which respectively accompany the vessels of this name.

1 Poirier, Delamere, and Cuneo. The Lymphatics, 1903.

112 INTESTINAL AND GASTRIC OPERATIONS.

"(a) The anterior cecal collecting trunks appear on the anterior surface
of the cecum. They run upwards and inwards, traversing one or two small
glands situated in the thickness of the anterior ileocecal fold, and then
terminate in a glandular mass placed on the terminal segment of the ileo-
colic artery.

"(b) The posterior cecal collecting trunks follow the course of the
artery of this name. Like the preceding, they traverse some small glands
— the posterior cecal. The latter, from three to six in number, are situated
on the posterior aspect of the cecum, at the junction of this surface with
the internal surface. Except in those rare cases where the coalescence
of the posterior surface of the cecum and the parietal peritoneum is com-
plete, these glands are covered by the visceral layer of peritoneum, which
binds them to the posterior surface of the cecum. The posterior cecal
lymphatics terminate in the ileocecal glandular group.

"(c) The collecting trunks of the appendix, four or five in number,
run up between the layers of the mesoappendix, accompanying the appen-
dicular artery. Like this artery they cross the posterior surface of the ter-
minal segment of the ileum, then penetrate into the mesentery, and ter-
minate in the ileocecal glandular group. In their course these lymphatics
traverse some small glands which we class under the generic term of appen-
dicular glands. In the large majority of cases these glands, from one to
three in number, are placed in the retroileal segment of the mesoappendix :
they may then be styled the retroileal appendicular glands. Finally some
of the glands of the mesoappendix may be placed immediately against the
cecum, above the origin of the appendix; these are the juxtacecal appen-
dicular glands.

"The Lymphatics of the Small Intestine. — The lymphatics of both
the large and the small intestine form two systems relatively independent
of each other, one of which is attached to the mucous layer, the other to the
muscular coat. The mode of termination of the collecting trunks of the
small intestine is not the same in the region of the jejunoileum as in that
of the duodenum.

"Lymphatics of the Jejunoileum. — The collecting trunks, which
are extremely numerous, make their appearance in the neighborhood of the
mesenteric border of the intestine. If examined in the living subject, during
intestinal digestion, they appear as slightly bossed channels of varying cal-
iber, especially noticeable on account of their milky appearance. Though
these glands appear, at first sight, to be indiscriminately scattered between
the two folds of the mesentery, if observed more attentively we may convince
ourselves that they are arranged on some fairly definite plan. It is also

THE ANATOMY OP THE INTESTINES. II3

possible to divide them into three groups which vary in importance and
signification.

"The mesenteric glands of the small intestine constitute one of the
most important glandular centers in the human system. They vary in
number from 130 to 150 (Quain), and their size varies greatly in different
subjects.

"These glands may be divided into three or more distinct groups:

"(1) The primary group is made up of some small glands placed in
the course of the terminal arterioles which spring from the last anastomotic
arch of the superior mesenteric artery (vasa recta). This group may be
considered as simple interrupting glandular nodules which have no mor-
phological fixity.

"(2) A second group comprises the glands placed in the course of the
primary branches of the superior mesenteric artery, at the level of the first
anastomotic arch formed by these vessels. These glands, which are larger
than the preceding, are the true regional glands of the small intestine.

"(3) The third group is found around the trunk of the superior mesen-
teric artery, and more particularly about the commencement of this vessel.
This group does not properly belong to the jejunoileum, as it receives, in
addition, the efferents of the regional glands of the cecum ascending and
transverse colon, duodenum, and even the efferents of certain glands con-
nected with the stomach.

"The second group of glands are especially numerous in the portion
of the mesentery which corresponds to the jejunum. There is a progres-
sive diminution in their number in each given segment of the mesentery
until the terminal segment of the ileum is reached. Here in this terminal
segment and in the ileocolic region of the mesentery the glands reappear
in numbers and form an important mass around the ileocolic artery. The
collecting trunks for these glands form two systems relatively independent
of each other, one of which is attached to the mucous coat, and the other to
the muscular coat of the intestine.

"Lymphatics of the Duodenum. — The lymphatics of the duodenum
end in numerous collecting trunks which are arranged on the same plan as
those of the jejunoileum, but the pancreas divides these vessels, like the cor-
responding blood-vessels, into two groups — an anterior group, the vessels
of which end in glands placed on the prepancreatic vascular arch ; a posterior
group, the lymphatics of which terminate in the satellite glands of the retro-
pancreatic arch. From these glands, the pre- and the retropancreatic,
run two systems of efferents. Some, ascending, terminate in the glands of
the hepatic chain. Others, descending, are grouped around the superior

114 INTESTINAL AND GASTRIC OPERATIONS.

mesenteric artery, at the spot where this vessel crosses the third part of the
duodenum.

"The close relations which exist between the lymphatics of the duode-
num, on the one hand, and those of the common bile duct, on the other,
should be noticed. We shall see, later on, that anastomoses are also
present between the lymphatics of the duodenum and those of the pyloric
portion of the stomach."

INTESTINAL LOCALIZATION.

Intestinal localization, as a surgical procedure, has been rendered a practi-
cal possibility by the researches of Monks. 1 Henke, 2 Sernoff, 3 Weinberg, 4
and Mall 5 have also done valuable work upon the position of the intestines
within the abdomen, but their results have so little bearing upon surgical
anatomy that they are omitted here.

The following description is a partial summary of the investigation
of Dr. Monks; it is illustrated with ten drawings kindly loaned by him:

In attempting to distinguish one portion of the small intestine from
another two main difficulties are encountered, (i) Although the upper
portion of the small intestine is called the jejunum, and the lower the ileum,
yet there is no fixed point of transition from one to the other. For this
reason we may be uncertain as to the correct name to apply to a large number
of coils of intestine whose position we may know by exact measurement. It
is better to locate a coil of intestine by its distance from the duodenojejunal
flexure than by classing it as jejunum or ileum. (2) Though the nomen-
clature is confusing, a further difficulty is added by the variation in the length
of the small intestine, which was found by Monks to range between fifteen
and thirty feet.

The first problem to be met after drawing out an intestinal coil through
an abdominal incision is to classify the coir according to its general position,
that is, whether the coil belongs to the upper, middle, or lower portion of
the digestive tube. The root of the mesentry of the small intestine is con-
nected to the posterior abdominal wall obliquely, the upper end being
attached just to the left of the second lumbar vertebra, the lower end to the
right iliac fossa, at an indefinite point about six inches distant from the first.

1 Monks, G. H. Trans. Am. Surgical Asso., 1903.

2 Henke. His's Archiv, 1891.

3 Sernoff. Internat. Monatschr. fiir Anat. u. Physiologie, 1894.
* Weinberg. Ibid, 1896.

5 Mall, F. Johns Hopkins Hospital Bulletin, Vol. ix, 1898, p. 197.

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THE ANATOMY OF THE INTESTINES. 117

The outer surface o£- the abdomen may be marked off in the shape of a
figure H, the crossbar being represented by a projection of the line of
attachment of the mesenteric root, the upright lines being placed at either
end. These lines will be situated obliquely in relation to the perpendicular
of the body (Figs. 80, 81). Roughly, the upper six feet of the small intes-
tine are usually confined to the left hypochondriac region, above the upper
of the side lines of the H. The middle portion of the intestine is usually
found in the middle of the abdomen, while the lower part is below the
lower side line of the H, in the pelvis or in the right iliac fossa.

In identifying the position of a certain coil of intestine several factors
should be considered.

(1) It would be of assistance to know the length of the intestine,
though the great variations in the measurement of the tube render it im-
possible to prophesy what it will be in an individual case. Monks has
found a certain number of times that a short intestinal tube was associated
with a short mesentery. As the terminal arterioles (vasa recta) were found
to be short also, in these cases of short mesentery, he suggests that the
length of the vasa recta may give a clue to the whole length of the intestine.
It is to be presumed that the mean length of the vasa recta is meant, since
Monks himself found that these vessels varied much in length according
to their position in the upper or the lower portions of the tube.

(2) The size of the intestine, though relative, has well-known charac-
teristics. The diameter is greatest at the upper end, diminishing gradually
until the lower third is reached, after which it remains the same down
to the ileocecal valve. It varies much in life at any given point under the
influence of distention and certain other conditions.

(3) The thickness of the intestine corresponds roughly to the size.
The thick upper portion acquires this quality from the extra width of
muscular walls, and from the presence of a large number of valvules, con-
niventes. Toward the lower end the intestine becomes thinner, the val-
vule conniventes lose their characteristic appearance of pinkish-white
rings until they wholly disappear at fourteen or fifteen feet below the end
of the duodenum.

(4) As to the color of the intestine, the upper part is bright pink or
red, with a large number of branching vessels. This color fades gradually,
as we go downwards, to a pinkish or a yellowish-gray. To Dr. Monks's

Il8 INTESTINAL AND GASTRIC OPERATIONS.

statement may be added the great contrast betweerf the cecum and the
lower end of the ileum, for though this portion of the small intestine may-
be lighter in color than the jejunum, yet it is much darker than the cecum,
the light gray tone of which offers a marked contrast to the darker shade
of the ileum.

(5) An examination of the blood-vessels of the intestine furnishes
some of the best evidence for the determination of the identity of a loop.
As the observations of Dr. Monks have already been quoted above on this
subject, it will only be necessary to state that, in the upper portion of the in-
testine, the mesenteric vessels have a simple arrangement, that is, in a single
arch which is placed at a distance from the intestinal border (long vasa recta).
As the lower end of the intestine is approached, the arrangement becomes
more elaborate, a second, or even a third, arch being superimposed upon
the other, the distance between the last arch and the intestinal border grow-
ing less. Near the lower end of the tube the vascular arrangement is less
clearly marked, and consists of a confusion of anastomosing branches,
from which spring a series of short vasa recta (Figs. 82, 83, 84, 85, 86, 87).

(6) The thickness and the transparency of the mensentery vary
very much in different subjects, the more obese the patient the more opaque
the mesentery. The thinnest part of the mesentery is adjacent to the thick-
est portion of the intestine, — i. e., the upper end. The mesentery becomes
thicker as we go downward, while the intestine becomes thinner. The
translucency also varies with individuals. Dr. Monks has found trans-
parent spots between the upper vasa recta in nearly all cases, regardless of
fat deposit. These spots, which he calls "lunettes," disappear at about
the eighth foot.

(7) Small masses of fat may be found in the lower third of the small
intestine which project from the mesentery toward the bowel. These tabs
of fat were seen many times by Monks, even in very thin subjects.

(8) The determination of the direction of any given loop of intestine
is of high importance, even after the general situation of the coil has been
located. The operations of gastroenterostomy and appendicectomy are
good examples of the circumstances when a knowledge of the direction of
the loop is an absolute necessity.

Monks, in working upon the cadaver, determines the direction of a

Fig. 82. — A loop of intestine, the middle of which is exactly three feet from the end of the duo-
denum. The gut is of large size. The mesenteric loops are primary and the vasa recta large, long,
and regular in distribution. The translucent spaces (lunettes) between the vessels are extensive. Be-
low, the mesentery is streaked with fat. The veins, which had a distribution similar to the arteries,
are for simplicity omitted from this and from the subsequent drawings. The subject from which
the specimen was taken was a male of 40 years, with rather less than the usual amount of fat. The
entire length of the intestine was twenty-three feet. (Monks.)

Fig. 83. — A loop of intestine at six feet. As compared with Fig. 82 the gut is somewhat smaller.
The vascularity of the intestine and mesentery is less. Secondary loops are a prominent feature. The
vasa recta are smaller. The lunettes are also present, but are not so large as in Fig. 82. The sub-
ject was a male of about 35 years, with an average amount of fat. The entire length of the intestine
was twenty feet. (Monks.)

119

Fig. 84. — A loop of intestine at nine feet. The secondary loops are large; the vasa recta are
somewhat irregular and show branches. No lunettes are present and the mesentery is streaked with
fat, and is therefore somewhat opaque. The specimen was taken from the same subject which fur-
nished Fig. 82. (Monks.)

Fig. 85. — A loop of intestine at twelve feet. The vessels are smaller. The primary loops are
lost in the fat, but secondary and even tertiary loops are visible. The vasa recta are shorter, more
irregular and branching. The specimen came from the subject which furnishes Figs. 82 and S4. (Monks )

Fig. S6. — A loop of intestine at seventeen feet. The mesentery is opaque, and small tabs of fat
begin to appear along the mesenteric border of the gut. The vessels are represented by a somewhat
complicated network and are seen with difficulty in the thick fat of the mesentery. The specimen
came from the subject which furnishes Figs. S2, Sa, 85. (Monks.)

Fig. 87. — A loop of intestine at twenty feet. The gut appears to be thick and large. The mes-
entery is quite fat, opaque, and large, and numerous fat tabs are present. The vessels which are com-
plicated are seen with difficulty, and are represented by mere grooves in the fat. The subject was a
stout woman, and the entire length of the gut was twenty-one feet. (Monks.)

12 3

THE ANATOMY OF THE INTESTINES. 1 25

doubtful loop in the following manner: The mesentery is drawn tight
and the fingers passed down to the attachment of the mesentery to the
posterior abdominal wall. Palpation between the thumb and forefinger
will make clear the line of mesenteric insertion, and disclose any twists in
the mesentery itself. After freeing any possible twists the loop is arranged
so as to be parallel to the line of attachment of its mesentery. This will
leave the upper end in a proximal, and the lower end in a distal position,
as it normally should be (Fig. 88).

The value of peristalsis in indicating the direction of the loop is usually
underestimated. Dr. Monks feels that it is not reliable, and suggests that
it may be impossible, in a given case, to tell whether the peristalsis does not
run backward.

In 1884 Nothnagel 1 produced intestinal contractions by the application

Fig. 88. — Showing the- method of determining the real direction of the gut by passing the thumb
down on one side of the mesentery, and the fore and middle fingers down on the other, in the direction
of the mesenteric loop. (Monks.)

of crystals of sodium and potassium to the surface of the gut. Bayliss and
Starling have shown upon normal animals that the peristaltic contractions
of the intestine, when evoked by local stimulation, are true coordinated
reflexes, which are carried out by the local nervous mechanism (Auerbach's

1 Nothnagel. Physiologie u. Pathologie des darms., Berlin, 1884.

126 INTESTINAL AND GASTRIC OPERATIONS.

plexus). They are independent of the connection of the gut with the central
nervous system, and travel only in one direction, from above downwards.
In 1887 Mall and Halsted 1 resected an intestinal coil, leaving it attached
by its mesentery. They then sutured the upper end of the loop to the lower
end of the alimentary canal, and the lower end of the loop to the intestine
coming from the stomach. Subsequent observations upon the intestines
of these animals both during life and after death showed that the peristaltic
wave of the reversed coil travelled in a direction opposite to that of the
unreversed intestine. Bayliss and Starling believe that the preponderance
of the descending contractions in the normal animal may be due to the
higher excitability of the fibers at the duodenal end of the gut, and to the
constant presence of ascending augmentor stimuli. The law of intestinal
peristalsis, as described by Bayliss and Starling, is comprised of two re-
actions: contraction above, and relaxation below the stimulated point.
In order to demonstrate the intestinal movements upon animals it was
necessary to isolate the intestines from the influence of the central nervous
system (section of both vagi, both splanchnics, or of abdominal ganglia).
The following remarks are quoted from a report of an experiment done by
Bayliss and Starling 2 upon an animal in which the intestines were still
connected with the central nervous system:

' ' On opening the abdomen in a warm saline bath, the intestines are seen
to be collapsed and absolutely motionless. Local irritation, electrical or
mechanical, either provokes no response at all, or if strong enough, causes
a local contraction limited to the stimulated spot. On inserting a rubber
capsule distended with air under pressure and connected with a piston
recorder, the lever of the recorder remains permanently motionless. If
contractions are present they are slight in extent and irregular in rhythm. "

The statement of Bayliss and Starling applies to the accurate observa-
tion of the intestinal reflexes. For surgical purposes it is not necessary
to produce contraction above and relaxation below the stimulated point,
a rough test is merely needed to indicate the direction of the peristalis.
Such a test is the following: An intestinal loop is drawn out, and its free
border given a sharp pinch with the fingers. The hand is quickly drawn
away in order to observe the beginning of the contraction which will be

1 Mall, F. Reversal of the Intestines, Johns Hopkins Hospital Report, Vol. 1, p. 93.

2 Bayliss and Starling. Journal of Physiology, 1899, Vol. xxiv, p. 120.

THE ANATOMY OF THE INTESTINES. 1 27

evoked. In response to the pinch there is no coordinated peristaltic move-
ment, but the muscle fibers which were grasped by the fingers slowly begin
to contract. The edges of the contracting area should be watched to see
in which direction the contraction first spreads, for the distal side reacts first.
In animals there is frequently a narrowing of the intestinal lumen both
upward and downward over an area of several inches, so that only the
earliest moment of the contraction is of importance. It is practically
always possible, in normal intestines, to orient the coil by this manoeuvre,
but the very beginning of the contraction must be watched in order to make
the test a success. In attempting to elicit a peristaltic reaction, a light
brushing with the finger-tips is not sufficient, since it usually requires a
firm pinch to obtain a contraction. Nothnagel's salt test has been recom-
mended by Senn 1 and others, but at present it is not regarded as a practical
surgical procedure.

1 Senn, N. Practical Surgery, 1901, p. 844.

CHAPTER IV.
OPERATIONS UPON THE INTESTINES.

(I) End-to-end Anastomosis,
(i) Plain.

(2) Mattress.

(3) Mechanical devices.

(a) Murphy button.

(b) Harrington ring.

(1) Suture in two layers.

(2) Purse-string.

(III) Lateral Anastomosis.

(1) Plain.

(2) Mattress.

(3) Mechanical devices.

(a) Jaboulay's button: ring; bobbin.

(b) McGraw rubber ligature.

(IV) End-to-side Anastomosis.
(V) Colostomy.

(1) Permanent.

(a) Left inguinal.

(b) Anterior.

(2) Temporary.

(a) Rubber ligature.

(b) Glass tube.

ENTERECTOHY.

The excision of a part of the intestine is frequently demanded. The
small intestine may be invaded at any point in its whole length by disease
which can only be cured by its removal. Although primary lesions of a

128

OPERATIONS UPON THE INTESTINES. 120.

serious nature are not often found in the jejunum, several cases have been
reported where infarction of the mesenteric vessels or penetrating wounds
have necessitated an operation upon this part of the gut, at its very beginning
where it is most inaccessible. No portion of the large intestine, from the
ileocecal valve to the rectum, is exempt from the possibility of operative
attack.

A list of certain of the indications for enterectomy is appended below
which conforms in the main with the views recently published by Moynihan ■}

New Growths. — The most common form of new growths which occurs
in the intestine is cancer, which, though occasionally met with in the small
intestine, is most frequently found in the colon and rectum. Tillmann
suggests that new growths tend to appear at points where the friction from
the passage of the intestinal contents is greatest, as in the cecum and at the
flexures of the colon. The same may be said of the sigmoid flexure and
of the rectum. In the small intestine small round-cell sarcoma is occasion-
ally encountered.

In resecting the intestine for malignant disease the mesenteric glands
should be palpated and removed with a good margin of mesenteric fat.
When no glands can be made out, a wide margin of mesentery is still neces-
sary since the mesenteric fat may be infected before the glands themselves
are large enough to be palpable. In excising the mesentery the margin
referred to should be taken down toward the root of the mesentery to get
between the infection and the deep glands.

Stricture may come as a result of inflammation or ulceration of the
inner surface of the intestine. This is occasionally secondary to the irrita-
tion of a foreign body, such as an enterolith, though the circular ulceration
which typifies the tubercular lesion in the lower portion of the ileum is a
more common cause of obstruction. Another condition to be classed under
the head of intestinal strictures which require resection is the chronic
intestinal obstruction which not infrequently follows abdominal operations.
Upon reopening the abdomen the small intestine may be found adherent
to the peritoneal surface of the scar of the first operation. 2 It seems prob-
able that, for an adhesion to form between the abdominal scar and a coil

1 Moynihan, B. G. A. Abdominal Operations, 1905, p. 303.

2 S. S. Records, Mass. Gen. Hospital, Vol. lxv, p. 83.

130 INTESTINAL AND GASTRIC OPERATIONS.

of intestine, some injury to the serous coat of the bowel is necessary. This
would only require a slight abrasion of the peritoneum, an accident which
may happen during any prolonged abdominal operation. In performing
secondary operations upon animals the great omentum is invariably found
fastened to the under surface of the scar of the first operation. Without
doubt the protection thus afforded by the omentum prevents the intestine
from becoming attached to the abdominal scar. In certain cases, when the
adhesions between the intestine and the scar are extensive, chronic intes-
tinal obstruction results. Here the lumen of the gut is constricted over an
area two or three inches in length, and a complete cutting off of the passage
of the intestinal contents is constantly threatened by the danger of kink for-
mation or of swelling of the mucous membrane lining the constricted coil.

Gangrene of the intestine is usually due to interference with the blood
supply. This may result from one of two causes: either from disease of
the blood-vessels, themselves, or from pressure exerted on the outside of
the intestine. When gangrene is associated with disease of the blood-
vessels either a venous or an arterial lesion may be present, the end result
being a progressive blocking of both the arterial and the venous trunks
with clots which are propagated into the main vessels, thus causing necrosis
of a considerable length of intestine. Examples of gangrene from outside
pressure are volvulus, constriction in a hernial sac, etc.

Among the other conditions which demand a removal of a portion of
the intestine are intussusception, which cannot be manually reduced ; gun-
shot wounds, or extensive lacerations of the intestine or its mesentery;
and intractable fecal fistula.

END-TO-END INTESTINAL ANASTOMOSIS.

The elementary precautions to be observed in suturing an intestine
end to end differ in no way from those required for any other form of technic.
Leakage of individual stitches may result from soiling of the suture line
with septic intestinal contents, from bruising of the cut edges, or from
inaccurate approximation of the peritoneum (Chapter II). It has become
recognized as a fact, since the knowledge of Schede's 1 work has become
diffused, that resection and anastomosis do not necessarily go together;

1 Schede. Deutsch. Med. Wochenschr., 1887, xm; Deutsch. Zeitsch. fur Chir., 1901, ixx, 59.

OPERATIONS UPON THE INTESTINES. 1 3 1

the indications for the former may be peremptory, while the latter may be
contraindicated. The presence of chronic obstruction implies a thickened
bowel above the lesion, associated with more or less distention. Unless
the cause of the symptoms is recognized early, the surgeon is likely to find
the intestines under the influence of cathartics. Since the peristalsis is
quieted by ether this contingency may be overlooked, only to find that the
intestinal action is violently resumed when the effect of the anesthetic wears
off. Anastomoses which are done under these conditions are subjected
to a great strain by the subsequent contractions of the muscular walls of
the intestines. In all but the more acute conditions, therefore, it is con-
sidered safer to perform the operation at two sittings, the first operation
consisting in resecting the diseased area, with the formation of an artificial
anus. After the gut has been allowed a complete rest, an end-to-end suture
can be performed with the best chance of success. 1

The studies of Monks 2 concerning drainage of distended intestines are
not out of place here. In view of the well-known fact that enterostomy,
done to relieve distention of the small intestine, is usually followed by the
escape of little gas or intestinal contents at the time of. operation, Monks
made several experiments upon the cadaver. Upon opening a number of
gas-distended coils he found in every case that the collapse of the gut, which
followed the escape of the gas, was a purely local one, only a coil or two
emptying its contents, while the rest of the intestine remained as distended
as before. He came to the conclusion, as far as dead or paralyzed bowel
is concerned, that the small intestine consisted presumably of various seg-
ments, not always opening freely into one another, which segments acted
as separate reservoirs for gas or other contents, and that the collapse, by
emptying one of them, did not necessarily mean the immediate emptying
of the others. After filling the intestinal loops with water and gas it was
found that the water, which occupied the most dependent portions of the
loops, acted as an efficient plumber's trap, separating the different segments
of the intestine. In addition to the obstacles presented by these traps in the
most dependent loops, where the water collects, semisolid contents and
kinks may act in the same manner. He also found that the weight of the

1 Treves. Operative Surgery, Vol. n, p. 323.

2 Monks, G. H. Annals of Surgery, October, 1905.
16

132

INTESTINAL AND GASTRIC OPERATIONS.

intestinal contents may press the sides of the gut so firmly together that
even the pressure within the adjacent distended gut is not sufficient, with-
out peristalsis, to open up the tube and allow the gas to pass on. A num-
ber of experiments were made to determine what lengths of intestine can
be gathered on a tube when the instrument was passed through an abdom-
inal wound of the ordinary length, and also through an opening into the gut

Fig. 89. — Showing how soon a straight instrument passed into the gut may engage its free border.

(Monks.)

"such as is made in most enterostomies. " Monks got the best results with a
glass tube the size of an ordinary lead-pencil, the extremity of which was
curved, with the opening on the concave side (Fig. 89) . He found that, if the
abdominal wound can be made long enough, and if ,the tube is of sufficient
length, the greater part of the small intestine may be gathered on the tube.
Moynihan 1 adopts a similar plan for drainage of the bowel in cases of ob-

1 Moynihan, B. G. A. Abdominal Operations, 1905, p. 279.

OPERATIONS UPON THE INTESTINES. 133

struction. He opens the bowel on the free border and inserts a glass tube
six inches long, after which he finds that he can readily draw from eight to
ten feet of intestine upon a tube of this length. Elliott's 1 technic for re-
section and drainage is the following: After resection he immediately
unites the mesenteric borders of the proximal and distal loops to facilitate
the subsequent closing of the artificial anus. Care is taken to wall off the
peritoneal cavity completely before allowing the contents of the proximal
distended intestine to escape.

Two practical dangers are incurred in anastomosing the bowels end to
end, — first, leakage from defective approximation at the mesenteric borders,
and, second, a subsequent obstruction' from turning in too wide an angle.
Before Maunsell and Connell introduced the mattress mesenteric stitch
this inaccessible portion of the circumference was fastened by means of
stitches which grasped the mesenteric insertion parallel to the long axis of
the bowel. The tying of these mesenteric stitches constricted the vasa
recta and subjected the line of anastomosis to a not remote danger of
anemic necrosis. This danger is eliminated by the use of the mattress
mesenteric stitch. Post-operative obstruction at the site of the joint is
caused either by taking the seromuscular stitches too far from the edge, or
by reinforcing the joint with a second layer of outside stitches. A dia-
phragm is thus formed which may either dam the intestinal current, else,
if the edge be turned in to a less degree, the bowel above the joint may be
forced down by the peristalsis and caught by the diaphragm, thus resulting
in an intussusception.

There are three principal methods by which an end-to-end anastomosis
may be made:

(1) The Plain Anastomosis.

(2) The Mattress Anastomosis.

(3) Mechanical Devices.

(a) Murphy button.

(b) Harrington ring.

Among the various methods of joining intestines end to end a few
are to be described in detail which are in wide use at the present time.

1 Elliot, J. W. Annals of Surgery, November, 1905.

134 INTESTINAL AND GASTRIC OPERATIONS.

Mechanical devices may have had their day; they certainly have proved of
the utmost value during the evolutionary period of gastrointestinal work.
But a large number of surgeons still prefer such instruments as the Murphy
button, the Harrington segmented ring, and the Robson decalcified bone
bobbin. Since there is a demand for mechanical aids in the surgery of the
intestinal tract, the author has thought it wise to explain the best and
the simplest methods of technic required for their use.

The plain anastomosis with two layers of stitches has already been
discussed at length. In the opinion of the majority of operators this technic
includes all of the essential requirements for this work. The accepted
advantages of the Connell mattress anastomosis are two: (i) The union
gains great strength by the penetration of each stitch through every coat
of the bowel. These stitches do not pull out if snugly tied, because the pull
is all sustained by the loop, which, being placed across the muscle-fibers,
cannot cut out through the lines of muscular cleavage. (2) This stout
grip of the mattress stitches allows their being introduced very close to the
cut edge of the bowel, so that practically no inversion results. It is not
possible to decide between the plain and the mattress anastomoses on the
ground of leakage dangers, for an accurate observance of the special points
of either technic should give a safe joint. It is evident, however, that the
most satisfactory work will be done by the operator who confines himself
to one of these methods, without attempting to become equally familiar
with all.

PLAIN END-TO-END ANASTOMOSIS.

Steps :

(1) Clamps.

(2) Resection.

(3) Mattress mesenteric stitch.

(4) First two guides to mesenteric border.

(5) Continuous suture of circumference through all coats.

(6) Seromuscular stitch, interrupted, or continuous.

(7) Approximation of cut mesenteric edges.

The coil of intestine to be resected is withdrawn from the abdomen,
and, to avoid subsequent soiling of the wound, the intestinal contents are
pushed to either side by stripping with the fingers. Clamps are then applied

OPERATIONS UPON THE INTESTINES. 135

to the intestine, at a right angle to the lumen, leaving a margin of about
three inches on either side of the area to be cut out. A good instrument
to use for this purpose is the straight circumcision clamp, the jaws of which
have been covered with rubber tubing. Finally, a handkerchief gauze is
wrapped around the intestines beneath the clamps to isolate the field of
operation from the abdomen. To prevent spilling out of whatever contents
are left in the resected portion, clamps or circular ties will be required. If
no intestinal clamps are at hand, straight half-length clamps may be used,
without covering. In resecting the bowel, there is always vigorous bleeding
from the terminal branches of the small vascular arches which run parallel
with the bowel, near the mesenteric attachment, — i. e., the vasa recta. These
vessels are best tied double and cut before opening the intestine, including
as little as possible of the mesenteric fat. The coil is now grasped by the
fingers of an assistant, about an inch on either side of the point at which
the incision is to be made, and the operator cuts carefully with a knife
through all coats of the bowel, wiping away the blood and the intestinal
contents with the left hand. It is better to finish the resection with scissors,
in order to watch each side as it is cut away (Fig. 90).

It has become traditional to cut away the bowel obliquely to make sure
of the blood supply at the free edge (Madelung 1 ). A slight obliquity is
necessary to aUow for the excess of inturned edge at the mesenteric border.
Sloughing of the joined edges will not occur, however, if the mattress mesen-
teric stitch is used, although, as mentioned before, the old method of joining
the mesenteric edges with stitches taken parallel with the bowel wall may
cut off the circulation and cause anemic necrosis of the joined edges. The
incision is finally continued down through the mesentery for two or three
inches, avoiding the evident vessels and tying when necessary. Finally,
the narrow pedicle of mesentery which remains is tied off and cut, which
completes the resection. Of the several ways of treating the mesentery
shown in Fig. 91, the best is the removal of a wedge-shaped piece, as de-
scribed in the text.

The placing of the Maunsell mesenteric stitch forms the starting-point
of the anastomosis. This should enter and leave the bowel a little more

1 Madelung, O. Verhandl. der Deutsch. Gesellsch. fur Chir., Berlin, 1881, x, pt. 2, pp.
414-464; Archiv fur Klin. Chir., Berlin, 1881-2, xxvn, pp. 277-326.

136 INTESTINAL AND GASTRIC OPERATIONS.

than one-eighth inch from the cut edge, but should penetrate the mesenteric
space and the peritoneum farther forward. This furnishes an ample width
of edge for the subsequent continuous catgut stitch, without separating the
bowel edges with a thick mass of fat (Fig. 92). The mesenteric third of
the bowel circumference is rather inaccessible, and, to bring this portion
forward, guide stitches are introduced. The scheme for developing the mes-
enteric border with the first two guides was originally described by Jabou-
lay and Briau, 1 but, as their method of placing the inner layer of stitches
is out of date, it has been here modified to include all the recent technical
improvements. To control hemorrhage, and to bring the cut edges together,
a continuous chromic catgut stitch is used, size preferably No. o. This
stitch starts a short distance to one side of the mesenteric border, where it
is tied outside of the bowel, leaving a long end to be used for the first guide.
A second guide is next placed on the opposite side of and at an equal dis-
tance from the mesenteric border, with its ends left inside, to invert the bowel
edges. The distance between the two guides should equal, approximately,
one-third the circumference. Upon tightening the guides the cut edges
between the two are exposed, and the continuous through-and-through
stitch passes across from one guide to the other (Fig. 93). When the
second guide is reached, a third guide is introduced half-way between the
first two, .on the free edge of the bowel, opposite the mesenteric attachment.
The ends of this guide are left outside. Traction on this, and on the lower
guides, will make easy the completion of the continuous stitch (Fig. 94).
The end of the continuous suture left after circling the circumference is
tied to the long end left on the first knot, and the guides removed. The
continuity of the chromic stitch must be broken occasionally by knots, so
as to make it difficult to narrow the lumen by drawing the catgut into a
purse-string, and, also, to give greater security to the joint.

The most important step in the anastomosis is the seromuscular suture.
Both continuous and interrupted stitches are employed for this purpose,
but the Lembert stitch is on the whole more reliable. The first interrupted
seromuscular stitch is placed on the free edge, opposite the mesenteric
border, and is followed by a stitch at the mesenteric border on either side.
The ends of these three stitches are left long, as they make excellent guides for
1 Jaboulay et Briau. Lyon Mddical, 1896, T. lxxxi, 19 Avril, p. 529.

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Fig. 91. — This figure shows several methods of sewing together the cut mesenteric edges after
resection of the bowel. None of the methods need explanation except the last two on the right, where
the bowel has been cut away without removing the usual V °f mesentery. The redundant mesentery
is folded on one side and tacked down to the mesentery on three sides. (Redrawn from Bickham.)

Fig. 92. — End-to-end Anastomosis.
Mattress mesenteric stitch.

139

Fig. 93. — End-to-end Anastomosis.

Sewing mesenteric third of circumference. Guides are held by an assistant. The guide on the left

is merely the long end left at the beginning of the continuous over-and-over stitch.

Fig. 94. — End-to-end Anastomosis.
Closing in the last third of the circumference. The guide on the right has been placed at a
point opposite the mesenteric border. The guide on the left is the original long end left at the first
knot, and was also used as a guide in sewing the mesenteric third.

141

OPERATIONS UPON THE INTESTINES. I43

the remaining stitches, which are introduced in -the usual way (Fig. 95). The

Fig. 95. — End-to-end Anastomosis.
Placing the interrupted Lembert stitches. Two interrupted stitches have already been placed at
the free and the mesenteric borders respectively. These first two stitches are used as guides to assist
in the introduction of the remaining interrupted stitches.

Fig. 96. — End-to-end Anastomosis.
The suture has been completed. The cut edges of the mesentery have been sewed together with

interrupted stitches.

mesentery is, finally, caught together with a few interrupted stitches (Fig. 96).

i 4 4

INTESTINAL AND GASTRIC OPERATIONS.

When doubt exists about the ability of the stitches to hold the joint
tight, it is possible to reinforce the suture line by grafting a bit of omentum
over the spot in question (Fig. 97, after Bickham). The following technic
is recommended by Senn for this procedure : A piece of the great omentum,
of the proper shape and size to cover the suture line, is cut off with scissors.
Senn immerses the grafts in saline solution and, later, presses them out
before fastening them in place. If the experience obtained in skin-grafting
can be applied to omental grafting, the soaking of the grafts is a disad-
vantage, as it deprives the tissues of blood (Porter). It is better that the

Fig. 97. — Omental Graft. (After Bickham.)

grafts be touched as little as possible before attaching them in place,
since any considerable handling must destroy their vitality. In my experi-
mental work upon repair, several sections were obtained in which adhe-
sions were present between the omentum and the suture line; in one case
only was the omentum attached intentionally, and then without cutting
it off from its blood-supply. In these sections the process of repair
appeared to have advanced more rapidly between the intestine and the
omentum than between intestine and intestine at the line of anastomosis.
If deductions can be drawn from animals, where the repair is very

OPERATIONS UPON THE INTESTINES. I45

active, grafting, on the whole, is not desirable, because the graft becomes
fastened to the neighboring intestinal coils, as well as to the suture line.
As a consequence, a mass of tangled adhesions may tie together several
loops of intestine.

Senn 1 states that the adhesions between omental grafts and intestinal
serosa seemed denser when the serosa had been prepared by gentle scoring.
This stimulates an exudation of serum, and, for this reason, was adopted
by Senn as a part of his technic.

The grafts are fastened in place by a few soluble interrupted stitches.

END-TO-END ANASTOHOSIS BY THE MATTRESS STITCH.
This anastomosis is known as the method of Connell. 2 It is an effective
adaptation of the mattress stitch to end-to-end anastomosis.
Steps :

(1) Three mattress stitches to the mesenteric border.

(2) Mattress guides develop one-third of the circumference.

(3) Mattress stitches to first third.

(4) Mattress guide to adjoining third of circumference.

(5) Second third of circumference everted and sewed from inside

with mattress stitches.

(6) Second third allowed to retract, and last third of circumference

sewed from outside.

(7) Last stitch, Cushing mattress.

(8) Approximation of cut mesenteric edges.

The mattress mesenteric stitch is introduced as before described. It was
explained under the technic of the plain anastomosis that it is always best
to complete the mesenteric portion of the joint before closing in the re-
mainder of the circumference. For this reason it is desirable to place
a mattress stitch on either side of the usual mesenteric stitch before pro-
ceeding with the rest of the suture. This point was suggested by Coffey
in his technic. The second and the third mesenteric mattress stitches
should be placed so close to the first that their inner halves also include a
portion of the mesentery (Fig. 98). One of the two outer mesenteric
stitches is left long for future use as a guide. The next step is to develop

1 Senn, N. Practical Surgery, 1901, p. 821.

2 Connell, F. G. Philadelphia Monthly Med. Journal, Vol. 1, 1899.

146

INTESTINAL AND GASTRIC OPERATIONS.

the cut edges of the first third of the bowel circumference. To do this, two
mattress guides are necessary, the first being placed on the side of the intes-
tine, at a distance from the mesentery which corresponds to one-third the
bowel circumference, while for the second guide the outer of the three
mesenteric stitches is utilized, the ends of which have been previously left
long.

In Fig. 99 the guides are taut, thus bringing forward the cut bowel
edges. The anastomosis depends wholly upon one layer of through-and-
through mattress stitches, introduced one-eighth inch from the edge, and
tied on the inside, as described in Chapter II. It is critical that the stitches

Fig. 98. — End-to-end Anastomosis, Connell Mattress.

Shows method of placing the three mattress mesenteric stitches. For the sake of clearness these

stitches have not been tied, although, actually, each stitch should be tied as soon as it is introduced.

be placed close together, else bleeding may occur from the cut edges between
stitches. Connell advises that the interval be not over one-eighth inch.
After completing the suture of the first third of the circumference, the
mesenteric guide is cut short, and a third mattress guide introduced, at a
distance from the second guide equal to one-third the circumference. After
tying this guide-stitch, the long ends of the second guide are passed beneath
this third guide. Traction upon the second and the third guides will turn
the mucous surface of the intestine outside in such a manner that the second
third of the circumference is brought forward, thus allowing the edges to be
easily sewed from the inside with interrupted mattress stitches (Fig. 100).

OPERATIONS UPON THE INTESTINES.

147

The second guide is now cut, and the everted portion allowed to retract
inside, leaving a small space to be closed in. It is possible, by placing the
second and the third guides very wide apart, to sew together three-fourths
the circumference of the intestine from the inside. At present Connell
sutures the circumference by halves instead of by thirds, a modification
which is made possible by placing the guides wide apart, as just stated.

The last portion to be closed in, between the third guide and the mesen-
teric border, is done as follows: The assistant holds the two coils side by

Fig. 99. — End-to-end Anastomosis, Connell Mattress.
First third of bowel circumference developed by guides A and B. The intervening space is being
closed with interrupted mattress stitches. Guide A is the outer mesenteric mattress stitch. Guide B
marks the first third of the circumference. The point C designates the site of the third mattress guide.

side between the thumb and the middle finger of the left hand, the first
finger being placed between the two coils and under the suture (Fig. 101).
The right hand draws down on the long end, which is always left on the
last stitch, thus rolling in the cut edges, as the new stitch is being placed.
When the stitch has been tied, the one just used as a guide is cut short,
and the last stitch taken is left long, with which to invert the edges for the
next stitch (Scudder). Although the stitches which approximate the last
third of the circumference penetrate the bowel edges in exactly the same

1 Scudder, C. L. Unpublished communication.

148

INTESTINAL AND GASTRIC OPERATIONS.

manner as those of the first two-thirds, yet, from the point of view of the
operator, they seem to be reversed. For this reason it will be well to bear
in mind that (i) the needle always starts from within the lumen; (2) the
needle always goes from mucous membrane to peritoneum, and from per-
itoneum to mucous membrane, or, m-p-p-m.

It is not possible to tie the last stitch without resorting to some expedient
to assist in turning in the peritoneum. Connell overcomes the difficulty
as follows: The blunt end of a needle is inserted between two stitches

Fig. 100. — End-to-end Anastomosis, Connell Mattress.
Guides B and C develop the second third of the circumference, their points of introduction being
shown in Fig. 99 . The circumference has been turned inside out by passing guide B beneath guide
C, and drawing tight the two ends, thus allowing the second third of the circumference to be sewed
from the inside.

at a distance from the stitch about to be tied, and the eye pushed up until
it emerges through the space to be closed in by the^last stitch. Both ends
of this stitch are threaded through the eye and are drawn out with the needle
until the free ends can be grasped outside the bowel. Here the ends are
tied and the knot allowed to retract into the lumen. This finishes the
suture, but many surgeons find it simpler to close in the last gap with a
Cushing mattress stitch, as shown in Fig. 102, than to adopt the rather
difficult suggestion of Connell. When well done, this anastomosis gives a

OPERATIONS UPON THE INTESTINES.

149

very strong, artistic joint, because the stitches penetrate all coats, and, when
tied, do not show on the outside.

MECHANICAL DEVICES.
Mechanical devices are used for two purposes: (1) for speed, (2) as a
support to hold the cut edges in place during the introduction of the outer

Fig. ioi. — End-to- end Anastomosis, Conneli. Mattress.
The everted bowel edges have been replaced and the last third of the circumference ; s now being
closed in by mattress stitches, which are apparently reversed. Note that traction on the long ends
left on the previous mattress stitch inverts the cut bowel edges, and thus assists in tying the next stitch.
Note also method of holding the bowel by assistant.

layer of stitches. Three devices are described below which contain practi-
cally all the advantages of mechanical aids. Although these instruments
actually do gain time, in the hands of experienced operators, they should
not be chosen for the apparent simplicity of their use. Each requires an
accurate knowledge of what the instrument can do, and the technic is based
upon this experience.

!5°

INTESTINAL AND GASTRIC OPERATIONS.

The Murphy 1 button is used mainly for speed, and offers a very rapid
method for end-to-end or for lateral anastomosis. It is not necessary
to give a careful description of the device, since its every feature is perfectly
familiar to all. In using the Murphy button the operator must place the
patient's life in the hands of the instrument -maker, for slight imperfections
in construction have repeatedly resulted in separation of the button halves
and leakage of the joint. The instrument has been modified in several
particulars since it was originally introduced, the improvements being
directed chiefly toward increasing the lumen of the inner tube.

Fig. 102. — End-to-end Anastomosis, Connell Mattress.
Introduction of last stitch, ends tied on the outside.

Steps :

(i) Clamps.

(2) Purse-strings.

(3) Resection.

(4) Introduction of button halves.

(5) Tying purse-strings.

(6) Halves of button snapped together.

(7) Sewing of mesentery.

1 Murphy, J. B. Chicago Med. Recorder, December, 1892; New York Med. Record,
December 14, 1892.

Fig. 103. — End to-end Anastomosis.
Introduction of the Murphy button. Note purse-string sutures, and clamps on button halves.

Fig. 104. — End-to-end Anastomosis, Murphy Button.
The button halves have been snapped together and the joint reinforced with a few interrupted

stitches.

I 5 I

OPERATIONS UPON THE INTESTINES. I S3

The application of the clamps is made in the same manner as in other
end-to-end anastomoses. The purse-strings should be of soluble material,
preferably No. 2 plain catgut. These sutures are introduced after the
method shown by Figs. 56, 57. A good margin is chosen on either side
of the area to be resected and the purse-string placed, a half-knot being
tied in the loose ends to save time later. The area to be removed is now
clamped off and the incisions made on the outer side of either clamp up to
one-eighth inch of the purse-strings. The removal of the resected portion
with its mesentery has been described under the plain suture. The un-
screwed halves of the button are seized with artery or special forceps,
inserted into the open bowel lumina, and the purse-strings tied down to the
male and the female tubes (Fig. 103). The forceps are then removed by
an assistant while the surgeon grasps the bowels close behind the button
halves to prevent their slipping back inside. The completion of the anas-
tomosis is accomplished by invaginating the male tube of one-half into the
female tube of the other, and thus forcing the peritoneal coats into tight
apposition (Fig. 104). The button is provided with a spring which will
make allowance for a certain amount of irregularity in the joined surfaces ;
but the mesenteric border will always remain a weak spot. This will be
recognized when it is remembered that the purse-string, by its inversion of
the bowel ends, draws with it a portion of the mesentery. Since this thick
wad of fat must be crushed before the joint can be made tight, it is safer to
put in an occasional interrupted stitch before closing the abdomen. When
used for lateral anastomosis, the button is placed between layers of equal
thickness, as the operation is done at a distance from the mesenteric border.
Here the joint can be made perfectly tight without danger of leakage. In
choosing a button for this work, an exigent examination must be made
of the spring and the screw-thread to make certain they are perfect. This
is especially true when the button has been previously used. It is to be
remembered that this instrument stays in place at least eight days, and
usually much longer. Its transit through the small intestine is attended
with vigorous peristaltic action and thus renders the convalescence rather
uncomfortable.

The Harrington Segmented Ring 1 and the Robson Decalcified

1 Harrington, F. B. Boston Med. and Surg. Journal, November 6, 1902.

154

INTESTINAL AND GASTRIC OPERATIONS.

Bone Bobbin 1 are constructed upon the same principle, their object being
to gain speed, without sacrificing the advantages of the seromuscular
stitch. Both of these instruments are reduced in size before they pass on, —
the ring by segmentation, the bobbin by solution. For this reason they
cause no discomfort from increased peristalsis. The ring is made of hard
aluminum in four sections. These sections are jointed firmly together by
a small bar of steel which has a shoulder and a screw-thread, and which
serves as a handle. The outer surfaces of the ring are grooved to hold the ends
of the intestines, which are tied in place by catgut purse-string sutures. The
segments fit together by means of sliding tongue-and-groove joints so rounded
that they will not cut or catch in the tissues. The ring is made in three sizes.

Diameter.
t inch

Width.

Wt. oj individual segments

\ inch

io grains

5 «
"8"

20 "

5 "

"S"

3° "

The bobbin, as described by Robson, 2 is "nothing more than a cylinder
of decalcified bone with raised ends." It is made in many sizes for adap-

Fig. 105. — End-to-end Anastomosis, Harrington Segmented Ring.
Actual size of smallest ring.

tation to a large variety of operations, from cholecystenterostomy to end-
to-end suture of the large intestine. Although the bone bobbin is a suc-

1 Robson, A. W. Mayo. Brit. Med. Journal, 1893, April 1, 1, 688, 689; Se"m. MeU, Paris,
1892, xn, 485.

2 Robson, A. W. Mayo, and Moynihan. Surgical Treatment of Diseases of the Stomach,
1904, p. 233.

Fig. 106. — End-to-end Anastomosis, Harrington's Segmented Ring.
Purse-strings, one tied, about ring. Mattress mesenteric stitch loosely placed.

Fig. 107. — End-to-end Anastomosis, Harrington's Segmented Ring.
Continuous seromuscular suture around circumference of joint.

ISS

OPERATIONS UPON THE INTESTINES. 157

cessful device, yet the necessity of keeping it in alcohol renders it rather
inconvenient to carry about. The segmented ring can be carried in the
layout with the other instruments and boiled (Fig. 105).
Steps for the Ring and the Bobbin :

(1) Purse-strings.

(2) Resection.

(3) Mattress mesenteric stitch.

(4) Introduction of instrument.

(5) Tying of purse-strings.

(6) Tying of mesenteric stitch.

(7) Continuous seromuscular stitch about joint.

(8) Removal of handle (ring).

(9) Approximation of cut mesenteric edges.

The first two steps are identical with the beginning of the button technic ;
but, with these instruments, we are able to fasten the mesenteric borders
of the gut securely by means of the Maunsell mattress stitch, described in
the plain suture and elsewhere. This stitch is placed immediately after
the resection has been done, and is loosely tied with a half -knot to save
time later. The material for this stitch should be No. o chromic gut. After
the mesenteric stitch is placed, the device is slipped into the ends of the open
bowels, and the purse-strings tied (Fig. 106). The mesenteric stitch is then
made fast, thus completing the preliminary steps of the operation. The
mainstay of the suture is the seromuscular continuous stitch. This brings
the circumference of the bowels together and turns in the edges which are
bound down to the instrument (Fig. 107).

In employing his bobbin for lateral anastomosis Robson does not use
a purse-string, a method which is applicable to end-to-end union. In
this technic one-half of the outer seromuscular stitch is first placed. The
cut edges are then sewed together from the inside with a continuous catgut
stitch, leaving just enough room for the introduction of the bobbin. When
the bobbin has been slipped into the lumen the through-and-through con-
tinuous catgut stitch is carried over the front and tied, after which the sero-
muscular stitch is taken up and the peritoneum closed over the last half of
the circumference.

i58

INTESTINAL AND GASTRIC OPERATIONS.

FORMATION OF A BLIND END.

It is occasionally difficult, or even impossible, to suture two cut in-
testinal ends in continuity. Such is frequently the case when it becomes
necessary to anastomose the ileum to the colon after resection. At other
times the character of the operation demands that the intestines be joined
side by side, or else by planting the end of one into the side of another.
As a preliminary step to the lateral anastomosis, a safe method is required
for closing the cut ends. Two methods are given:

(i) Suture in two layers (old).

(2) Purse-string.

rfW 9

Fig. 108. — End-to-end Anastomosis, Robson's Decalcified Bone Bobbin.
Two layers of sutures : inner, purse-string; outer, seromuscular. The outer stitch is in reality continu-
ous, although shown diagrammatically as interrupted.

SUTURE IN TWO LAYERS.

This is the classical technic. It is slightly modified here by the addition
of the reversed mattress stitch. This method is especially indicated in
closing in the large intestine, since the edge turned in is a very narrow one.
The purse-string, or second method, may be used on the large intestine
when plenty of leeway can be left between the puckered end and the second
joint; otherwise the routine suture in two layers should be adopted.

Steps :

(1) Clamps, and resection.

(2) Continuous inner stitch to bowel and mesentery.

(3) Interrupted mattress stitch to peritoneum.

OPERATIONS UPON THE INTESTINES.

J 59

The clamps are applied and the resection done as usual. The intestine
is closed with two layers of stitches. The inner is a continuous through-
and-through suture, which starts at the free edge of the bowel, and approxi-

Fig. 109. — Formation of Blind End (old).
Inner continuous Glover's stitch to bowel and mesenteric edges.

mates the cut edges from above downwards. When the mesentery is
reached the stitch is continued down over it, thus securing any small vessels
which have been cut during the resection (Fig. 109). The outer sero-

Fig. no. — Formation of Blind End (old).
Outer layer of reversed mattress stitches.

muscular layer of stitches may be either interrupted or continuous. A
strong close approximation is obtained by applying the reversed mattress
stitch, as shown in Fig. no.

160 INTESTINAL AND GASTRIC OPERATIONS.

THE PURSE-STRING OPERATION.

This operation has been developed and improved by various American
surgeons. The originators of the technic were Doyen, 1 Bardenheuer, 2
Winiwarter, 3 and others. This is a very rapid and safe method. Its main
disadvantage consists in the wide edge of bowel which is invaginated by
the purse-string. In situations where the width of the turned-in edge is
of no consequence the technic is perfectly satisfactory. It is commonly
used for closing the duodenum after pylorectomy (Mayo).

Steps :

(i) Purse-string suture.

(2) Clamp.

(3) Resection.

(4) Cut edges sewed with through-and-through catgut suture.

(5) Clamp removed.

(6) Invagination of sewed-over cut edges, with tying of purse-

string.

(7) Interrupted stitches to end of bowel.

If possible, the purse-string should be placed before opening the bowel.
In this instance an insoluble stitch is desirable because the purse-string is
the mainstay of the joint and is used to bring together the serous coats. A
clamp is now placed across the intestine, about one-quarter inch from purse-
string, on the side of the proposed resection. For this purpose a straight
half-length clamp is usually large enough, although sometimes a longer
clamp may be necessary. The jaws are not protected by rubber, as the
portion of the bowel grasped by them will be turned in. The intestine is
next cut away with scissors, leaving an edge of one-quarter inch attached
to the clamp. In order to add security against an accident to the purse-
string and to control the bleeding, the cut edges are sewed together with
a through-and-through soluble stitch extending from the free edge well
down over the triangular mesenteric space (Fig. in).

The clamp is now removed and the circumference of the bowel grasped

■'.Doyen. Chirurgen Congress Verhandlungen, 1898, p. 200.

2 Bardenheuer. Experimented Beitrage zur Abdominal-Chirurgie, Inaugural Dissertation,
1888, p. 68.

3 Winiwarter. Verhandlungen der Deutsch. Gesellsch. fiir Chirurgie, 1891, I, 133.

OPERATIONS UPON THE INTESTINES.

j6i

with the left hand, while the right invaginates the sewed-over cut edges
with forceps. When the rough edges have been tucked in in this manner
the purse-string is drawn tight and tied by the assistant, thus closing the

■

i
1

N
I

H}A^ni

Fig. ii i. -Formation of Blind End. Fig . 1 I2 ._ The sewed-over cut edges
Fig. in shows purse-string in position with ends have been invaginated, and the purse-
lightly tied in a half-knot. The cut intestinal end is string tied. Note how the mesentery is
grasped between the jaws of a clamp while the edges are drawn up into the dimple; also note the
sewed together with an over-and-over stitch through all reinforcing interrupted stitches (seromus-
coats. cular).

Fio. 113. — Formation of a Blind End. Cross section.

bowel end. The tightening of the purse-string draws up part of the cut
edge of the mesentery, and thus fills the dimple resulting from the pucker-
ing-in with a thick plug of fat. As an extra precaution, a few seromuscular
stitches are added. When a lateral anastomosis is to be done (by Abbe's

162 INTESTINAL AND GASTRIC OPERATIONS.

method *) the two cut ends must be closed by the above technic ; when an
end-to-side, only one blind end need be made (Figs. 112, 113).

LATERAL INTESTINAL ANASTOMOSIS.
This operation consists in joining two intestinal coils, or the intestine
and the stomach side by side, with the establishment of a fistulous opening
between the attached organs. It was devised for the purpose of conducting
the intestinal stream around an obstruction when resection was contrain-
dicated. It is now used for many conditions where no obstruction is present.
The following are the methods used for performing the lateral anastomosis :

(1) Plain suture.

(2) Mattress suture.

(3) Mechanical devices.

(a) Jaboulay's button; ring; bobbin.

(b) McGraw rubber ligature.

PLAIN SUTURE.
This is considered the safest and best technic.
Steps :

(1) Clamps.

(2) First seromuscular stitch.

(3) Intestine opened.

(4) Through-and-through continuous stitch.

(5) Seromuscular stitch continued over front of joint.

A fold, about three inches long, is picked up] on the free edge of the
bowel with the fingers of the left hand. The clamp pinches in this fold,
with care to include only just enough to allow the suture to be done. The
constant secretion of mucous from the inside of the opened gut makes
it desirable to have as little as possible of the mucous membrane exposed
during the operation. If the cut bowel ends" have been previously turned
in, the clamps should allow a good margin, to avoid contusion of the closed
ends (Fig. 114).

The actual suture is done in two layers: (1) the inner continuous,
through-and-through of all coats, and (2) the outer seromuscular. It is

1 Abbe. MedicaljRecord, 1892, Vol. xli, p. 365.

OPERATIONS UPON THE INTESTINES.

163

more convenient to place the first half of the seromuscular stitch before
opening the bowel, for, in this manner, the two coils are steadied together,
while opening the gut and placing the inner stitches. The first continuous
stitch is placed longitudinally, about one-fourth inch from the free edge
of the bowel extending over a distance of about four inches. The thread
is left long at each end of the suture, especially at the last knot, since this
long end is to be used later to cover in the front of the joint. The incisions
into the bowels are made longitudinally, and exactly opposite the mesen-
teric borders. The cuts are best made with long, free strokes of the knife,
and should be about one-eighth inch shorter at each end than the first con-

Fig. 114. — Lateral Intestinal Anastomosis.
Note the position of the clamps in relation to the closed ends. Also note the method of attaching
the cut mesenteric edges. The remaining technic for the lateral anastomosis will be shown under
gastroenterostomy.

tinuous stitch. A margin of one-fourth inch is to be kept laterally, between
this stitch and the bowel incision. During the operation, the bleeding
from the cut edges is prevented by the clamps, and, to control this upon
their removal and strengthen the suture, the cut edges are sewed together
with a continuous No. o chromic stitch. The details of placing the inner
through-and-through stitch are to be found under the technic of posterior
gastroenterostomy. The conclusion of the stitch is accomplished by
invaginating the continuous chromic stitch with an outer layer of sero-
muscular stitches, which is continued over the front by the long end left
from the first outside stitch.

164 INTESTINAL AND GASTRIC OPEEATIONS.

THE MATTRESS SUTURE.

In performing lateral anastomosis by means of Connell's mattress
method the technic described for the end-to-end anastomosis is followed
as closely as possible.

Steps :

(1) Clamps.

(2) Intestine opened on either side at once.

(3) Three mattress stitches to incision angle.

(4) Interrupted mattress stitches to circumference.

The clamps should be first applied in the long axis of the bowels, in
the manner adopted for the plain suture. When the clamps are placed in
this way it is much easier to open the intestine, as the folds are held in
exactly the proper position. The intestinal incisions are made as usual,
with long sweeps of the knife down to the mucosa, when scissors are sub-
stituted for the knife to cut away the redundant mucous membrane. The'
removal of the redundant mucous membrane is fully illustrated under the
technic of Finney's gastroduodenostomy. In beginning the suture three
mattress stitches are placed at one angle of the wound, the upper of the
three being left long to mark the point of ending after the whole circum-
ference has been closed in. Interrupted stitches are next placed across
the base line from one incision angle to the other, thus joining the cut edges.
When the second angle is reached the stitch is left long to be used as a guide
in sewing the second portion of the circumference. Up to this time guides
have not been required because the clamps have held the edges in apposition.
The eversion of the anterior cut edges is more difficult in lateral than in
end-to-end anastomosis, and cannot be accomplished without changing
the clamps. The intestinal openings are carefully filled with gauze, and
the contents stripped back with the fingers for a distance of three or four
inches, at which point the clamp is reapplied at a right angle to the axis
of the gut. When no obstruction is present, in either of the attached coils,
four clamps will be needed to prevent leakage from the bowel lumen, one
above, and one below the opening into each intestine. To approach the
second portion of the circumference a mattress guide is introduced into
the anterior cut edges at a point half way between the incision angles, in

OPERATIONS UPON THE INTESTINES. 165

a manner exactly similar to that described for the end-to-end union. The
gauze is removed from the bowel lumina and the long ends of the stitch
left at the second incision angle are passed under the anterior guide and
are gently drawn tight. The mucous membrane is thus turned inside
out and held by drawing the two guides steadily apart. In everting this
second portion of the circumference great care must be exercised to avoid
tearing the stitches out of the tissues, because the counter pull of the clamps
and of the attached intestines is often difficult to overcome. The com-
pletion of the anastomosis is a repetition of the end-to-end technic. The
everted portion of the circumference is sewed together and replaced, after
which the gap remaining is brought together by interrupted mattress
stitches which are apparently reserved. The last stitch is placed from
the outside. The continuous mattress stitch has been favored by M. E.
Connell 1 for lateral union, but, although more rapid, it is less safe than
the interrupted method on account of the danger of slipping.

MECHANICAL DEVICES.

(a) Jaboulay's button; ring; bobbin.

(b) McGraw rubber ligature.

Jaboulay's Button. 2 — This mechanical device, which is constructed
in a general way upon the principle of the Murphy button, has been used
with apparently good results, for some years, in the clinic of Jaboulay in
Lyons. The reference given is Jaboulay's most recent description of
the button. The experimental work done by Beer 3 with the Jaboulay
button does not support the claims made by the inventor of the instrument.
Beer describes the mechanism of the button as follows: "Each half is
made up of two cylinders, an outer and an inner. The outer is perforated
with drainage holes, just as in the Murphy button, though the openings
are of different contour. At one point in the outer cylinder there is a
distinct break in the continuity of this cylinder ; this gap or slit is prolonged
into the inner cylinder, and continues almost half way around the inner
cylinder. It measures, in a 22-millimeter size button, approximately one-

1 Connell, M. E. Medical Record, 1892, Vol. xlh, p. 335; Journal Am. Med. Asso., 1893,
Vol. xxi, p. 150; North Am. Practitioner, September, 1898.
" Jaboulay. Medizinsche Klinik, March 12, 1905.
3 Beer, E. Annals of Surgery, November, 1905.

1 66 INTESTINAL AND GASTRIC OPERATIONS.

eight of the diameter of the button. It is vertical in the outer cylinder,
running through its entire thickness; whereas, in the inner cylinder, it is
at first vertical, corresponding to the slit in the outer cylinder, but very
shortly bends at right angles, and runs, as said before, almost half-way
around the inner cylinder. In this slit the Jaboulay idea is concentrated.
By means of this slit the button can be introduced into the lumen of the
bowel through a small opening. Naturally the same slit arrangement
is present in the male and female halves of the button, and these fasten
into each other by means of a screw thread arrangement, somewhat similar
to the mechanism of the Murphy button. As the outer cylinder has been
interrupted, by the slit which runs through it, to obtain approximation of
the two pieces of bowel at this point when the buttons are driven home,
Jaboulay had to prolong the mesial margins of the outer cylinder, — *. e.,
the margins which come in contact with each other when the buttons are
approximated, otherwise there would be leakage at this point. The
prolongation of this margin is in the form of a thin, elongated metal plate,
which acts like a weak spring in closing the slit in the upper or mesial
border of the cylinder. The extra cylinder of the Murphy button, which
works on a spring and whose function is to force and hold the two apposed
serosa surfaces against each other, and eventually produce their necrosis,
is not used in the Jaboulay button. In this button the apposition and
subsequent necrosis are produced by the operator's forcing the two halves
>of the button very firmly together."
Steps :

(i) Clamps.

(2) Bowel incisions one centimeter long.

(3) Introduction of button halves.

(4) Joint snapped together.

The presence of a longitudinal groove through the flanges of the button
halves allows them to be put in sidewise. The halves are held separately
with artery forceps, as is usual with the Murphy button, and the edge of
the intestinal cut slipped into the slit in the side of the flange. By rotating
the button, it will screw itself into the intestinal lumen through an opening
which has a diameter much smaller than the largest part of the button.
Jaboulay steadies the cut edges of the opening with forceps, while twisting

Fig. 115. — Lateral Anastomosis with Jabotjlay's Button.
One-half of button being turned into intestinal opening, the portion of the flange already within the

lumen showing faintly through.

Fig. 116. — Lateral Anastomosis with Jabotjlay's Button.
Both halves of the button are in place, ready to be snapped together. Note absence of purse-strings .

167

OPERATIONS UPON THE INTESTINES. 1 69

the button into position. The two halves are finally snapped together
forcibly and the joint thus completed (Figs. 115, 116). Beer did not find,
experimentally, that a button 22 millimeters in diameter could be screwed
into an opening one centimeter long without tearing the bowel. He
reports that eighteen tears in the serosa resulted from introducing twenty-
eight button halves, all of which required sutures to close the rents. In
no instance, however, did the mucosa prolapse through these rips, as it
does through the larger incisions used for the Murphy button technic.
Beer saw no bad results from the tearing or stretching of the opening,
but regards the contrivance as inferior to the Murphy button.

In summarizing his experiments, Beer states that the Jaboulay button
actually offers an increase in speed over the Murphy button, but two min-
utes being required for the technic. The small intestinal incision, though
of advantage in doing away with sutures, results in tears of the bowel wall.
Finally, the halves must be driven home with great force in order to insure
necrosis of the included tissues, although, even then, the button frequently
becomes so fixed in the joint that it is not passed. The Jaboulay button
has been little used in this country, and the results of experimental work
are discouraging. The technic is described here without advice as to its
adoption.

The Harrington Ring. — This technic differs in no particular from
the end-to-end method, with the single exception of the omission of the
mesenteric stitch. The placing of the purse-string for lateral anastomosis
is shown in Fig. 58. Harrington puts in the first half of the seromuscular
stitch before opening the bowel.

Steps :

(1) Purse-string.

(2) First half of seromuscular stitch.

(3) Bowels opened, ring introduced.

(4) Second half of seromuscular stitch.

With this method the exposure of the field of operation to infection from
the opened intestine is reduced to its minimum time. The purse-strings
are placed at the desired points, with both arms of the loop parallel and
about one-fourth inch apart. The bowels are next attached with a sero-
muscular stitch which projects a short distance over each end of the purse-

170 INTESTINAL AND GASTRIC OPERATIONS.

strings. The incisions are then made and the ring slipped into the lumina,
where it is fastened in place by tying the purse-strings. The seromuscular
stitch is finally carried around the remainder of the circumference, and
the joint thus completed. The removal of the handle is done at the last
moment, just before the last stitch is taken, and the hole left is covered by
the outer continuous stitch.

The Robson Bone Bobbin. — This device has been previously described.
In lateral anastomosis the use of the button is merely a slight elaboration
over the customary method of suture in two layers.

Steps :

(1) Clamps.

(2) First half of seromuscular stitch.

(3) Incisions.

(4) Inner through-and-through stitch.

(5) Bobbin introduced.

(6) Second half of seromuscular stitch.

The placing of the clamps in the long axis of the viscus, the seromuscular
continuous stitch, the incisions, the inner through-and-through continuous
stitch, are all done in the routine manner. Before closing in the front of
the joint, with the inner through-and-through stitch, a bone bobbin of the
proper size is introduced, and the inner stitch closed over it. The outer
continuous seromuscular stitch is taken up again and used to bury the
portions of the inner stitch which are still uncovered.

The McGraw Rubber Ligature.— The use of the rubber ligature for
the lateral anastomosis of hollow viscera has become identified with the
name of McGraw. Although the actual originator of the method was
J. M. Gaston, 1 it was the practical technic of McGraw which brought the
method into favor. Since McGraw's first article appeared 2 there have been
various minor improvements suggested, all of which were summarized by
F. T. Murphy 3 in a paper which contains several useful original details.
The technic described below is, substantially, that recommended by Mc-
Graw and by Murphy. The ligature is made in three sizes : large, 5 mm. ;

1 Gaston, J. M. Atlanta Med. and Surg. Journal, 1884-5, v °l- h PP- 336, 385; Ibid., 1885-6,
Vol. n, pp. 395, 533-

2 McGraw. Journal Am. Med. Asso., 1891, Vol. xvi, p. 685.

3 Murphy, F. T. Boston Med. and Surg. Journal, January 28, 1904.

OPERATIONS UPON THE INTESTINES. 171

medium, 4 mm.; small, 3 mm. The largest size is very much stronger
than the others, and cuts out rapidly, but the medium size (4 mm.) is pref-
erable on account of its elasticity. Ochsner prefers the smallest size.
The needle which McLean 1 has devised to hold the ligature has rendered
the technic simpler (Fig. 117). This needle is made in several sizes. In
place of an eye a hook is substituted at one end, over which the ligature
is stretched and caught. The rubber is prevented from slipping off by a
movable ferrule which is forced down over the ligature as it is held by the
hook, thus tightly joining the end of the ligature to the needle. The size
of the ligature must be carefully chosen so that the ferrule cannot work

Fig. 117. — McLean Needle for the Rubber Ligature.
Enlarged in diameter. Method of attaching the ligature to the needle.

loose. One case has been reported where the ferrule slipped down over
the rubber with unfortunate results. 2

The limitations in the use of the McGraw ligature are not well defined.
It has been used with success in cholecystenterostomy, gastroenterostomy,
and in lateral intestinal anastomoses, and is a rapid and safe method, even
in patients of poor vitality. There has been a prevailing opinion that it
is a dangerous technic to employ in bad subjects, or in tissues of poor
vitality. The Mayos 3 and Ochsner, 4 however, have had excellent results
with the elastic ligature in gastroenterostomy. W. J. Mayo states that
the ligature will cut through in patients with poor resistance, if the tissues

1 McLean. Journal Mich. Med. Soc, Detroit, 1903, 11, 550.

2 McGraw. Journal of the Michigan State Med. Society, August, 1904.

3 Mayo, W. J. Annals of Surgery, November, 1905.

4 Ochsner. Journal of the American Medical Asso., October 21, 1905.

172 INTESTINAL AND GASTRIC OPERATIONS.

have even a small vitality, but that when the intestinal or the gastric walls
have lost the power to produce an inflammatory reaction, the ligature will
not cause a slough of the tissues within its grasp. One of the great recom-
mendations of the rubber ligature is the short time required for its intro-
duction; Mayo finds that twelve minutes are sufficient for a gastroenter-
ostomy, while McGraw 1 has performed this operation in three minutes.
In comparing this with other methods of gastroenterostomy, in cases of
patients with poor resistance, Mayo expresses a feeling that there is more
danger of uncircumscribed slough or infection when the Murphy button
or the suture in layers is used than when the ligature technic is adopted.

The two objections commonly advanced against the use of the elastic
ligature are the following: (r) In the process of freeing itself by pressure-
necrosis of the included tissues, from three to five days are demanded, during
which period the advantages attributed to the immediate drainage following
suture and certain mechanical operations are lost. McGraw argues,
however, that patients are not able to avail themselves of the new channel
until after a lapse of from two to three days, on account of gastric irritability
and refusal of the stomach or intestine to contract, in the presence of an
injury to its walls. The experience of Dr. McGraw is not wholly corrobo-
rated by that of other operators who have been successful in feeding patients
on the day following the operation, where the anastomosis was made with
sutures. (2) The second objection raised has to do with inaccurate technic.
In a certain number of cases, as pointed out by McGraw himself, 2 the
needle may not enter the lumen of the bowel but may turn before freeing
itself of the mucosa, an error which is alluded to later in the technical
description. When such a condition exists, a portion of the mucous mem-
brane will not be grasped by the rubber band. As a result, when the
ligature has contracted as far as possible, it will be held in place by a bridge
of uncrushed tissue, which will prevent the subsequent discharge of the
ligature. This is a fault in technic which is easily avoided by plunging
the point of the needle well into the cavity of the organ before gathering
the fold on the needle.

Although this method of anastomosis has not been accepted as adapt-

1 McGraw. New York Med. Journal, January 26, 1001.

2 McGraw. Journal Am. Med. Asso., May 16, 1891.

OPERATIONS UPON THE INTESTINES. 173

able to all lateral anastomoses, it has a recognized place in gastrointestinal
surgery. The method should not be employed to make a pyloroplasty or
a cholecystenterostomy. 1
Steps :

(1) Clamps omitted.

(2) Preliminary continuous seromuscular stitch.

(3) Rubber ligature knotted in middle and threaded at both ends.

(4) Needle introduced into lumen, picking up longitudinal fold

of bowel 2§ to 3 inches long.

(5) Ligature put on stretch and pulled through to knot in middle;

same process repeated in second coil.

(6) Two ends tied in square knot and held with silk while first

line of sutures is depressed with forceps.

(7) Front and ends buried with interrupted stitches.

Clamps are not necessary because the only openings made in the bowels
are plugged by the ligature. The two coils are first fastened in place with
a seromuscular stitch, to steady the suture in a manner exactly similar to
that adopted for the plain lateral anastomosis. Murphy found that the cut-
ting out of the ligature advanced more rapidly under the knot, and, for this
reason, advises that a second knot be placed at the other extremity of the
suture. This is done by tying a half-knot in the middle of the ligature
after which both ends are threaded. The point of one of the needles is
introduced into the lumen of the bowel at a right angle to the axis of the
gut. The operator must make certain that the point is free of the mucous
membrane before turning, else the ligature cannot completely cut out the
fold. The needle is now turned and pushed up the lumen until it has
gathered a longitudinal fold of bowel about three inches long, when
the point escapes from the bowel as nearly as possible at a right angle
with the wall. The needle is grasped with artery forceps while the ligature
is held by the knot in the left hand. By separating the hands the rubber
is put on the stretch and is pulled through to the knot, an assistant wiping
away with a moist sponge the intestinal contents which are brought out
on the needle and the ligature. After repeating this manoeuvre on the
second coil, the ends are ready to be knotted (Fig. 118).

1 Ochsner. Journal of the American Medical Asso., October 21, 1905.

174

INTESTINAL AND GASTRIC OPERATIONS.

To prevent including the preliminary continuous stitch in the knot,
this suture is depressed with forceps, and the ends of the rubber ligature
tied in a half-knot over a piece of strong silk (Fig. 119). While the operator

Fig. 118. — Lateral Anastomosis by theMcGraw Ligature.
The first seromuscular stitch has been placed. The rubber ligature has been introduced with
two needles. Note knot on left (Murphy) in middle of rubber ligature to increase the speed of the
cut-out.

holds the ligature ends tight, the silk is tied over the front in a square knot,
thus securing the rubber from slipping. The second half of the knot is
completed in the same manner as the first half. After tying the rubber
ligature it will be noticed that the longitudinal folds which it grasps are
puckered into a number of wrinkles. This puckering will, later, flatten
out when the ligature cuts through, if the front and ends are buried in with
interrupted stitches (Fig. 120). It is probable that a continuous stitch
does not allow complete relaxation of the wrinkles when it is used to bury
in the front, and may thus partly constrict the opening. The complete
cutting through of the ligature requires from four to five days. It is neces-
sary to tie the rubber as tightly as possible, because, if loosely done, the
rubber will stop cutting before it has freed itself, and leave two holes instead
of one free opening (Figs. 121, 122).

Fig. 119. — Lateral Anastomosis by the McGraw Ligature.
The ligature is being drawn taut, thus dragging the two knots together. Note method of depress-
ing the first seromuscular suture with the blunt end of forceps. Note position of silk tie which is to
secure the knot in the rubber ligature from slipping.

JPWk/*

Fig. 120. — Lateral Anastomosis by the McGraw Ligature.
This shows the three stages of the technic. On the right the first seromuscular continuous stitch
is visible, while, to its left, the intestine is puckered up by the rubber ligature, which has been tied tight
and cut close. On the extreme left are seen the interrupted seromuscular stitches with which the whole
front of the joint will be closed in.

175

OPERATIONS UPON THE INTESTINES.

177

END-TO-SIDE INTESTINAL ANASTOMOSIS.

(Author's Method.) 1
After resection of the ileocecal valve, and certain other operations, the

Fig. 121. — Lateral Anastomosis.
A cross section of the anastomosis, McGraw ligature.

m ' 4k ' i%

Fig. 122. — Lateral Anastomosis by the McGraw Ligature.

From a photograph to show the actual opening made by means of the elastic ligature between the stomach

and jejunum. Specimen taken from cat. (Murphy.)

ileum is anastomosed to the large intestine. A lateral anastomosis is very
effective (Abbe) ; 2 but it requires the closure of two blind ends. The end-

1 Gould, A. H. Boston Med. and Surg. Journal, December 29, 1904.

2 Abbe. Medical Record, 1892, Vol. xli, p. 365.

178 INTESTINAL AND GASTRIC OPERATIONS.

Fig. 123. — End-to-side Anastomosis (Author).
Shows the method of application of the first mattress stitch. The dotted line on the small intestine
indicates the line at which corners will be cut off. The small dots on the edges of large and small bowels
show the points where the first two guides are placed.

Fig. 124. — End-to-side Anastomosis (Author).
The first mattress stitch has been tied and the first two guides pulled tight. The mesenteric third
of the circumference of the small intestine has been approximated to a symmetrical portion of the distal
edges of the cut into the colon, by an over-and-over stitch. The third guide has been loosely introduced
to show the correct position.

Fig. 125. — End-to-side Anastomosis (Author).
The suture is nearly completed, the seromuscular layers being approximated by a new mattress stitch.
Old mattress A brought to A. New mattress B brought to A.

to-side operation implants the cut end of the small intestine into the side
of the colon. The following technic was worked out on animals:
Steps :

(1) Clamps.

(2) Ileum resected obliquely.

(3) Incision into colon.

(4) Mesenteric border of ileum fastened into distal angle of cut in

colon, by a mattress stitch.

(5) Guides develop mesenteric border.

(6) Through-and-through stitch of all coats.

(7) Interrupted seromuscular stitch, either reversed mattress, or

Lembert.

(8) Cut mesenteric edge attached to colon, or adjoining structure.
The application of the clamps is not shown in the drawings. The small
intestine should be clamped at a right angle, about three inches above
the cut end, while the clamps on the large intestine are also placed at a
right angle, a short distance to either side of the incision. The open small
intestine to be implanted is first split along its free border, for one-half
inch to an inch (Fig. 123), and the corners which project are trimmed
down with scissors, so that an oblique opening is left, with edges rounded
out near the mesenteric border. The reason for rounding the edges at the
mesenteric border, instead of cutting them straight, is that it allows more
tissue for sewing at this point. The receiving intestine is opened on its
free edge for about one and one-half inches, and the distal end of this cut
fastened by a mattress stitch to the mesenteric border of the entering bowel.

n&&U*r

Fig.

a2 3-

Fhj.

124.

Fig.

J25-

179

OPERATIONS UPON THE INTESTINES.

151

Guides are placed, with the ends inside, to invert the cut edges and expose
the mesenteric third of the entering bowel, side by side with a symmetrical
portion of the cut edges of the receiving bowel (Fig. 124). The remainder
of the suture is finished exactly as in the plain end-to-end anastomosis.
The author's mattress or the interrupted Lembert stitches are both useful
for the seromuscular layer (Figs. 125 and 126). The cut edge of the
mesentery of the small intestine is finally attached by interrupted stitches
to the colon and the posterior abdominal wall, if possible, to avoid hernia
of the intestines beneath the arch. The degree of obliquity at which the
small bowel is attached to the large is not fixed. The adaptation of the

Fig. 126. — End-to-side Anastomosis.
Cross section.

mattress mesenteric stitch to this technic requires that a wider edge be
turned in at the distal angle of the wound, where this stitch is attached,
than necessary for the rest of the circumference, just as has been noted in
the plain end-to-end anastomosis. To counteract the pull made by this
stitch, the entering bowel must be cut slightly on the oblique, and this will
leave the two intestines fastened at right angle when the suture is com-
pleted. The old method of attaching the end to the side by the technic of
lateral anastomosis occasionally leads to stricture formation, and, on this
account, it is safer to give the entering bowel a more oblique attachment
than would be absolutely necessary to overcome the pull of the mesenteric

182 INTESTINAL AND GASTRIC OPERATIONS.

stitch, thus forming an opening which has a larger caliber than that of the
entering bowel.

If the steps of this operation are followed carefully, a joint will be
obtained which will be as strong and as safe as the plain end-to-end or the
lateral anastomoses ; while on the other hand, the danger from sepsis and
prolonged time-requirement will be minimized.

COLOSTOMY.

By colostomy is meant the establishment of an artificial opening into
some part of the colon. This opening may be either permanent or tempo-
rary, and the technic is modified according to the permanency of the opening
desired. There are two methods of approaching the colon for purposes of
drainage, — extra- or intraperitoneal. The extraperitoneal route is called
lumbar colostomy, an operation which was formerly regarded with great
favor on account of its avoidance of the peritoneal cavity, but which has
now fallen into disuse. It is said to be indicated in cases where the sigmoid
flexure has a short mesentery, or is otherwise bound down to the posterior
abdominal wall. According to Treves, 1 a mesocolon may be expected on
the left side in thirty-six per cent, of all cases, and on the right side in twenty-
six per cent. In view of these facts it is evident that it would not be possible
to open the colon, extraperitoneally, in a large number of cases. Improve-
ments in aseptic technic have removed the chief indications for the lumbar
route, allowing the bowel to be approached directly through the peritoneal
cavity. Lumbar colostomy has, for the above reasons, been omitted from
the list of operations to be described.

In the great majority of cases, colostomy for disease of the lower sig-
moid or rectum, or both, is done in the left inguinal region; but, in case of
involvement of the colon higher up, the transverse colon may be opened
in the median line, or, if necessary, the ascending colon in the right inguinal
region, always above the diseased section of bowel. 2 The location of the
incision for inguinal colostomy is not regarded at present to be of great
importance, provided that it is made below the level of the umbilicus, be-
tween the outer edge of the rectus muscle and a point at least one inch

1 Treves, F. Applied Anatomy, 1892, p. 346.

2 Gant, S. G. American Medicine, June 24, 1905.

OPERATIONS UPON THE INTESTINES.

183

internal to the anterior superior spine of the left ilium. The operations to
be described are the following:
Permanent Colostomy.

(1) Left inguinal.

(2) Anterior.
Temporary Colostomy.

(1) Rubber ligature.

(2) Glass drainage tube.

■ '

5K'"
3*

Fig. 127. — Left Inguinal Colostomy.
Line of incision.

LEFT INGUINAL COLOSTOMY.

(Allingham, Maydl, Gant.)

GantV accepts Allingham's 3 technic as the most reliable. He combines
it with Maydl's 3 muscle-splitting operation, as follows :

1 Gant, S. G. Diseases of the Rectum and Anus.

2 Allingham. Brit. Med. Journal, 1892, 1, p. 1013.

3 Maydl. Cent, fiir Chir., 1888, No. 24.

1 84

INTESTINAL AND GASTRIC OPERATIONS.

Steps :

(i) Incision, muscle-layers separated.

(2) Sigmoid withdrawn from the abdomen.

(3) Mesosigmoid drawn taut and made fast with stitch.

(4) Circumference of bowel attached to skin.

(5) Dressing, resection after adhesions have formed.

The skin incision is made nearly at right angles to an imaginary line,
drawn between the navel and the anterior superior spine of the left ilium

Fig. 128. — Left Inguinal Colostomy.
Method of placing stitches. 1. Mesenteric stitch; 2, Anchor stitch at either angle of wound.

(Fig. 127). This cut is about two and one-half inches long and is placed
two inches to the inner side of the iliac spine, one-third of the incision being
above, and two-thirds below the line just mentioned. The three muscle-
layers are separated in the lines of cleavage of their fibers (Maydl) and the
abdomen entered through an opening of about one and one-half inches.

The sigmoid is next located, and the length of its mesentery determined
at once. Occasionally, the mesentery is very short, or absent, when it is
not possible to bring the bowel far enough forward to employ this technic
with success. The loop is pulled upward until the afferent and the efferent

OPERATIONS UPON THE INTESTINES.

185

arms are taut (Allingham), in order to forestall the possibility of prolapse.
To form the spur, and prevent the intestine from slipping back into the
abdomen, an insoluble or a chromic-gut stitch is introduced, as follows:
While the loop is still taut, the needle is thrust through the skin in the
middle of and about half an inch from the edge of the lower lip of the wound.

Fig. 129. — Left Inguinal Colostomy.
Coils drawn together by mesenteric stitch. Interrupted stitches attaching bowel to skin.

After penetrating the skin, the needle picks up a bite of the afferent arm
of the loop under the mesenteric attachment. The stitch then crosses
behind the mesentery, and is passed through the mesenteric attachment of
the efferent loop, whence it penetrates the skin again, and is tied to the first
end (Fig. 128). In tying the stitch just described, the two arms of the loop
are drawn together, thus forming an efficient spur. The skin incision
is next closed in, at either end, with interrupted stitches, until it fits the

i86

INTESTINAL AND GASTRIC OPERATIONS.

bowel snugly on all sides, after which a row of interrupted catgut stitches
fastens the bowel to the skin. At either angle of the incision the catgut
stitch penetrates beneath the longitudinal band (Fig. 129). If sufficient
obstruction is present to demand relief, a glass tube is attached to the coil
in the manner shown in the next operation. The bowel is otherwise left
without drainage until adhesions have hermetically sealed in the abdominal
cavity. The resection is done four or five days later; Gant insists upon
leaving from one-fourth to one-half inch free edge of bowel above the skin

level, as accidents occasionally result
from retraction of the bowel into the
abdomen. The bleeding from the
cut bowel-edges is best controlled by
a running catgut stitch, around the
circumference, through all coats (Fig.

i3°)-

In cases where the sigmoid lies
unopened on the surface of the abdo-
men for several days while awaiting
resection, great care must be taken to
avoid compression of the coil, else
the circulation of the intestinal con-
tents will be impeded. The perito-
neal surface is coated with vaselin
or with zinc oxid powder, and this
covered with gutta-percha tissue, to
anticipate and prevent adhesion to
the dressing. A wall of dressing

is built up on all sides of the bowel, in such a manner that obstruction

cannot result.

ANTERIOR COLOSTOMY.

(MlXTER. 1 )

The principle of using the rectus muscle as a sphincter to assist in the
control of the motions has been brought out in the writings of Weir, 2 von

1 Mixter, S. J. Unpublished Technic.

2 Weir. Journal Amer. Med. Asso., xxxv, p. 1458.

'A -'■{'! i (us '-,, .

J- I-

Fig. 130. — Left Inguinal Colostomy.
Afferent and efferent coils amputated \ to
\ inch above level of skin. Continuous cat-
gut stitch about circumference of bowel.

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2 3

187

Fig. 133. — Anterior Colostomy.

Sigmoid withdrawn, mesentery pulled taut and incised. Rectus muscle sewed

together between afferent and efferent coils.

1S9

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O 3

10 1

OPERATIONS UPON THE INTESTINES.

193

Hacker, 1 and others. The operation, presently to be described, is really
an adaptation of AudryV method of left inguinal colostomy, although it
was devised several years ago by Dr. Mixter, without knowledge of Audry's
work.
Steps :

(i) Right-angle incision through skin and rectus fascia.

(2) Lid of skin and fascia reflected outwards.

(3) Separation of fibers of rectus muscle.

(4) Peritoneum opened, loop of sigmoid withdrawn.

(5) Mesosigmoid split at right angle to long axis of bowel.

(6) Rectus muscle sewed together between afferent and efferent

arms of bowel loop.

(7) Skin flap pulled through opening in mesosigmoid and sewed

into original position.

(8) Glass drainage-tube fastened into coil, if obstruction is present.

(9) Resection of loop, after four days.

As shown in Fig. 131, the incision commences at the level of the navel and
passes downward for about two inches, cutting skin, subcutaneous tissue,

Fig. 136. — Cross Section of Anterior Colostomy (Horizontal).
Section of sigmoid. Left rectus abdominis, 'at junction with oblique and transversalis muscles. Flap of

skin and fascia.

superficial and rectus fascia;. Tire line of this part of the cut is parallel
to the fibers of the rectus muscle, a short distance inside of its outer border.

1 Von Hacker. Beitrage zur Klin. Chir., xxin, 1899, p. 62S.
' Audry. Archives prov. de Chir., 1892, Vol. 1, p. 347.

194 INTESTINAL AND GASTRIC OPERATIONS.

At this point the knife turns inward, at a right angle, then downward, and
again outward, to form three sides of a square, the length of each of which
will be approximately two inches. The cut finally turns downward at a
right angle for two inches, as if in continuation of the first leg of the incision,
parallel with the fibers of the rectus. The lid of skin, subcutaneous tissue,
superficial and anterior rectus fasciae is dissected away from the belly of
the rectus muscle, and reflected outward (Fig. 132), after which the muscle
fibers are separated longitudinally by blunt dissection near the outer border
of the muscle, and the peritoneum opened. The sigmoid is withdrawn
from the abdomen, and drawn taut as in the previous operation. The
mesosigmoid is split at a right angle to the long axis of the bowel for a dis-
tance of about two inches, and the cut edges of the incision held apart,
while the middle portion of the separated rectus muscle is sewed together
with through-and-through catgut sutures (Fig. 133). The coil of sigmoid
now arches across the approximated portion of the rectus muscle, and under
this arch the lid of skin and fascia is drawn, to be fastened firmly into its
original position with two layers of interrupted stitches, one for fascia, the
other for skin. If acute obstruction is present, drainage is established
by inserting a right-angled Mixter l glass tube of large caliber, held in place
with a purse-string stitch (Fig. 134). The bowel is finally dusted with zinc
oxid powder, and covered with gutta-percha tissue to prevent the peritoneum
from adhering to the dressing. After four or five days the dressing is re-
moved, and the coil of sigmoid resected with scissors from a quarter to a
half -inch above the skin, on either side, trimming the mucous membrane
flush with retracted muscular coats. Bleeding from the cut edges of the
bowel circumference is controlled by a continuous suture of catgut, as in
the inguinal colostomy (Fig. 135). The proximal and the distal openings
are now wide apart, and a satisfactory sphincter is formed by the rectus
muscle. The separation of the bowel openings prevents feces from gaining
access into the distal coil. The distal opening is used for washing out
the contents which accumulate if the rectum is obstructed. Fig. 136
shows a cross section of the operation before the resection has been done.

1 Mixter, S. J. Boston Med. and Surg. Jour., 1895, Vol. cxxxn, p. 206.

OPERATIONS UPON THE INTESTINES. 195

COLOSTOMY WITH THE RUBBER LIGATURE.

(McGeaw. 2 )

McGraw advises the following technic for resection of tumors of the
large intestine:
Steps :

(1) Exploratory abdominal incision.

(2) Withdrawal of coil involved in growth, new abdominal incision,

if necessary.

(3) Rubber ligature anastomosis, between afferent and efferent

coils of loop.

(4) Resection of growth; efferent coil closed; temporary drainage

of afferent loop, with a glass tube.

(5) Afferent opening shut up, after four or five days, when ligature

has cut out; abdomen closed.
The abdominal incision is made directly over the growth, when the latter
can be located; otherwise, in the median line. If the incision has been
purely exploratory, a second opening is added, immediately over the tumor,
and the exploratory opening closed. The coil of large intestine involved
in the growth is drawn out through the abdominal opening, and its mesentery
palpated for glands. A lateral anastomosis is first performed, with a rubber
ligature between the two arms of the loop, proximal and distal to, and about
three inches distant from, the tumor (Fig. 137). The ligatured portion is
slipped back into the abdomen, and the growth clamped off, preliminary to
a resection. Purse-strings are placed around the circumference of the bowel
on either side of the area to be resected, and the field of operation walled
off with gauze. In resecting the bowel, the side distal to the growth is first
completed, the open end of the efferent gut being turned in by Mayo's
method. The stump, thus formed, is now tucked back into the belly, and
the abdominal incision closed over it, up to the point of exit of the afferent
coil. The proximal side of the diseased area is, finally, cut away, with its
V of mesentery, leaving a safe margin, and the glass tube, slipped into the
afferent coil, is fastened in place by tying the purse-string suture, already
introduced. The clamp, which has held back the intestinal contents, is

2 McGraw. Annals of Surgery, November, 1904.

196 INTESTINAL AND GASTRIC OPERATIONS.

taken off, and drainage is established through the tube (Fig. 138). A few
interrupted stitches attach the afferent coil to the skin, at its point of emer-
gence. After four of five days the cutting out of the rubber ligature will
be signalled by the resumption of rectal movements. When this occurs,
the afferent loop is closed in, and replaced within the abdomen, and the
abdominal wall sewed up over it. Fig. 139 shows the position of the anas-
tomosis with relation to the line of the abdominal incision. Caution must
be exercised in piercing the distended afferent loop with the rubber ligature
that the bowel wall be not torn.

TEMPORARY COLOSTOMY WITH GLASS TUBE.

This method is adopted to sidetrack the fecal current. It is of value
as a preliminary step to any suture of the large intestine. Gant advises
its use in the presence of many lesions of the lower bowel.

Steps :

(1) Bowel fastened to surface, as in permanent colostomy.

(2) Insertion of glass tube, incision parallel to long axis of intestine.
The early steps of the operation consist in fastening the gut to the surface
of the skin. This operation, though temporary in nature, is only relatively
so, since the colostomy is frequently kept open several months for purposes
of treatment. The colon is fastened to the surface by the usual method, pre-
ferably by the Allingham-Maydl-Gant technic. The glass tube is fastened
into the bowel by means of a purse-string, the incision being made parallel
to the long axis of the gut. Fig. 134 shows the method of inserting the
glass tube.

c
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B) c a

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197

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Fig. 139— McGraw's Colostomy with Resection.
Line of original incision. Large intestine visible through the abdominal wall. Lateral anastomosis

with ligature seen under incision.

199

CHAPTER V.
OPERATIONS UPON THE STOMACH.

GASTROTOMY.— GASTROSTOMY: WITZEL, SSB-ANAJEW -FRANCK.— PYLORODIO-
SIS: HAHN, LORETA.— PYLOROPLASTY: HEINECKE -MIKULICZ.— GASTRODUO-
DENOSTOMY: FINNEY, KOCHER.— GASTROENTEROSTOMY: POSTERIOR, ANTE-
RIOR.— PYLORECTOMY.— PARTIAL GASTRECTOMY.— EXCISION OF ULCER.— GAS-
TROPLASTY.— GASTROGASTROSTOMY.— GASTROPLICATION.

GASTROTOMY.

Robson and Moynihan 1 give the following indications for exploration
of the stomach:

i. For the removal of foreign bodies from the stomach.

2. For the removal of foreign bodies from the lower end of the esophagus.

3. For dilating a stricture of the esophagus.

4. For dilating a stricture of the pylorus.

5. For the removal of a polypus, or other tumor, projecting into the

stomach.

6. For exploration in case of intractable or bleeding ulcer.

7. For curetting cancer of the pylorus in Bernay's operation.

Steps :

(1) Examination of anterior wall.

(2) Examination of glandular groups.

(3) Examination of posterior wall.

(4) Walling off.

(5) Anterior wall opened parallel to vessels, or over foreign body.

(6) Treatment of interior, closure of stomach.

Exploration of the stomach may be done: to remove a foreign body
from the stomach, or from the esophagus; to dilate a stricture of the
stomach or of the esophagus ; for treatment of special lesions, such as bleed-
ing gastric ulcer. There is a difference of opinion about the value of
lavage, preliminary to exploration of the stomach, although most writers agree
that it is desirable to evacuate its contents as far as possible before operating.

1 Robson and Moynihan. "The Surgical Treatment of Diseases of the Stomach,"
Second Edition, p. 32.

202 INTESTINAL AND GASTRIC OPERATIONS.

The abdomen is entered through a free incision, and the stomach
brought forward. The anterior wall is first examined, by inspection and
by palpation, to locate any indurated areas. If pyloric stenosis is suspected,
the caliber of the sphincter is gauged with the finger, a portion of the
anterior wall being invaginated for this purpose. A thorough investi-
gation of the glandular groups is next carried out, since ulcer, or malignant
disease, send their metastases to pathognomonic groups. Lund 1 has pointed
out the value of "sentinel glands" to indicate the site of ulcers of the stomach.
A discussion of the lymphatic drainage of the stomach is included in the
technic of pylorectomy. If the anterior wall and the pylorus are free from
disease, the stomach is lifted forward, and its posterior wall inspected.
Adhesions of the mesocolon to the stomach may give a clue to disease on
the posterior wall.

The exploration of the interior of the stomach is done through an incis-
ion on the anterior wall. When foreign bodies or tumors are plainly palpa-
ble, the opening is made directly over them; otherwise, the incision is
placed in the center of the stomach parallel to the vessels. Before making
the opening the stomach is pulled out and carefully walled off from the
abdomen with gauze. It is possible to bring in review the whole of the
posterior wall by inserting the hand through the gastrocolic omentum
(Fig. 140), and pushing forward the posterior wall with the fingers. When
the mesocolon is adherent to the posterior wall, this manoeuvre must be
done without entering the lesser peritoneal cavity. After accomplishing
the object desired, the stomach is closed with two layers of sutures.

GASTROSTOMY.

This operation consists in the establishment of a more or less permanent
artificial gastric fistula, which has its outer opening in the abdominal wall.
It is employed for the purpose of feeding, or for treatment in cases of ob-
struction of the esophagus and of the cardiac end of the stomach.

Owing to the number of operations in use, some difficulty is encountered
in choosing the best technic. Berndt 2 states that, in establishing a gastric

1 Lund, F. B. Boston Medical and Surgical Journal, 1902, Vol. cxlvi, p. 469.

2 Berndt. Arch. f. Klin. Chir., Berlin, 1905, lxxvi, 905-916.

Fig. 140. — Gastkotomy (modified from Cheyne and Burghard).
The anterior wall of the stomach is held apart by retractors. The posterior wall is pressed forward by

the lingers in the lesser peritoneal cavity.

203

OPERATIONS UPON THE STOMACH. 205

fistula, the technic should be adopted which allows a subsequent complete
and spontaneous closure of the fistula, after it has served its purpose. The
spontaneous closure of the fistula is rarely desired in the large class of cases
of malignant obstruction for which this operation is usually demanded, so
that this factor is of less importance than at first appears. Berndt divides
the operations for gastrostomy into three classes : 1. Those in which a sphinc-
ter is formed in the abdominal wall itself (Hacker, 1 Girard, 2 Ullmann, 3 and
others) ; 2. Those in which a portion of the gastric wall is drawn out in a cone
(Hahn, 4 Ssbanajew, 5 Franck 6 ); 3. Those in which a canal is made in or
through the anterior gastric wall (Witzel, 7 Fischer, 8 Marwedel," Kader 10 ).
In reviewing the reported cases Berndt found that the sphincter made from
the abdominal musculature alone had given few favorable results. The
cases done by von Hacker's original method were obliged to use special
apparatus, such as a rubber balloon, to protect the skin from the digestion
and irritation which results from the leakage of the gastric juice over the
abdominal wall. It is a procedure which has not held its place beside
more practical methods.

The originator of the cone operation was Hahn, who made an incision
immediately below the left costal border. He perforated the eighth
intercostal space, from below upward, through which hole he drew the
stomach, using the elastic costal cartilages as a stop-cock. Although this
method is effectual, it is said that the fistula gradually becomes enlarged,
and occasionally leads to necrosis of the costal cartilages, which accounts
for its limited use. Ssbanajew, Franck, and Albert have modified Hahn's
technic so that a cone of the stomach is brought through the rectus
muscle and fastened under a bridge -of skin by means of a second incision
over the costal cartilages. Berndt is positive that this operation, by its
inherent peculiarities, does away with the possibility of a spontaneous

1 Von Hacker. Wien. Klin. Wochenschr., 1890, m, 348.

2 Girard. Korrespondenzblatt fur Schweizer Aertze, 1888.

3 Ullmann. Wien. Med. Wochenschr., 1894, xliv, 1662-1664.

4 Hahn. Centralbl. fiir Chir., Leipzig, 1890, xvn, 193-195.

5 Ssbanajew. Centralbl. fiir Chir., 1893, No. 40.

6 Franck. Wien. Med. Wochenschr., 1893, S. 231.

7 Witzel. Centralbl. fur Chir., 1891, S. 601.

8 Fischer. Deutsch. Chirurgenkongress, 1895.

9 Marwedel. Beitrage, z. Klin. Chir., 1896, Bd. 17, S. 56.
10 Kader. Centralbl. fur Chir., 1896, S. 665.

206 INTESTINAL AND GASTRIC OPERATIONS.

closure. In all forms of cone and canal operations subsequent observa-
tions show that the two openings of the gastric fistula tend to approach each
other. This apparently does not interfere with the continence of the valve,
if the rectus muscle is used as a sphincter. In Witzel's canal-forming
operation a catheter is sewed into the stomach, and the latter attached
to the abdominal wall. This has proved to be a good method, but it has
a limited application in cases where the stomach is too contracted to furnish
the proper gastric surface into which to bury the catheter. This objection
also holds against the cone operation.

The Witzel and the Ssbanajew-Franck technics are described in this book
because it is felt that they are the most popular operations. In conditions
where the stomach is too small to allow these operations to be used the
technic devised by Marwedel or by Kader may be employed, in which but
a small portion of the gastric wall is required.

WITZEL'S GASTROSTOMY.

Steps :

(i) Incision; exploration of stomach.

(2) Stomach withdrawn from abdomen, and catheter buried in

anterior wall, the eye pointing to the left.

(3) Point of catheter inserted into stomach, for two inches, and

opening buried.

(4) Line of suture buried, with a second layer of seromuscular

stitches.

(5) Stomach anchored to abdominal wall by two interrupted

stitches.

(6) Closure of abdominal wall; wicks.

The abdomen is entered through the fibers of the left rectus muscle, between
the ensiform cartilage and the umbilicus. The opening should be large
enough to allow easy exploration of the stomach, the point to determine
being whether or not the stomach is contracted to such a degree as to make
the operation impossible. If the stomach is large enough for the purpose,
it is withdrawn from the abdomen, and its anterior wall drawn downwards.
A large catheter, or a rectal tube, is buried in the anterior wall with sero-
muscular stitches, for a distance of three inches, parallel to the lesser curva-
ture, with the eye of the catheter pointing upward and to the left as high

Fig. 141. — Witzel's Gastrostomy.
Catheter partly buried in stomach. Guide stitch above opening. Interrupted stitches placed before

inserting point of catheter.

Fig. 142. — The eye of the catheter has been inserted within the stomach. Interrupted stitches ready

to tie.

207

OPERATIONS UPON THE STOMACH.

209

as possible. The higher the eye is placed, the less likely is regurgitation
to take place. Before opening the stomach, a guide stitch is introduced,
just above where the opening is to be made, in order to steady the stomach
as it is being incised. Two interrupted stitches are next introduced, but
not tied, over the point where the opening is to be made. A quick thrust
of the knife opens the stomach, and
the redundant edges of mucous mem-
brane are trimmed away with scis-
sors (Fig. 141). The catheter is
now slipped into the stomach for

Fig. 143. — Witzel's Gastrostomy.
Stomach fastened to anterior abdominal wall by
interrupted stitches. These stitches penetrate all
layers, including the anterior rectus fascia. The
ends are left long to assist in removal, later.

Fig. 144. — Witzel's Gastrostomy, Cross
Section.
Eye of catheter is in the cavity of the
stomach. Note the various layers through
which the catheter passes.

about two inches, and its hole of entrance buried by tying the inter-
rupted stitches already placed (Fig. 142). It is safer to close in the line
of suture with a second layer of seromuscular stitches, placed from
above downward. As soon as the eye of the catheter enters the
stomach, the outer end of the catheter is clamped to prevent leakage.

2IO INTESTINAL AND GASTRIC OPERATIONS.

The stomach is finally anchored to the abdominal wall. Mixter accom-
plishes this by means of two interrupted stitches which pick up the
stomach on each side of the lower exit of the catheter. One arm
of the stitch penetrates all the abdominal layers, through, and including,
the anterior fascia of the rectus muscle, and is tied to the other arm as it
lies across the cut edges of the abdominal wound (Fig. 143). The abdomen
is closed, in layers, or with through-and-through stitches, as preferred.
Small spaces are left above and below the exit of the catheter for purposes
of drainage, which is done with cigarette wicks. The ends of the stitches
which anchor the stomach are left long, outside of the abdominal wound,
and are used to assist, later, in the removal of the stitches themselves, after
the stomach has become firmly fixed to the abdominal wall by adhesions.
Feeding may commence at once, if necessary; the wicks are removed on
the second day. Fig. 144 is a cross section.

The catheter is kept in place as long as artificial feeding is necessary,
since the fistula will tend to close on the withdrawal of the tube, thus render-
ing its subsequent introduction difficult. It is customary to remove the
catheter while carrying out Abbe's treatment for esophageal stricture
(cutting stricture with string).

THE SSBANAJEW-FRANCK GASTROSTOMY.
This technic has been repeatedly modified by various surgeons. The
method described here is the one most commonly accepted.
Steps :

(1) First incision, parallel to ribs, rectus split.

(2) Second incision, above costal margin, parallel to first.

(3) Bridge of skin, between two cuts, raised by blunt dissection.

(4) Cone of stomach wall pulled out, and passed under bridge.

(5) Closure of skin over first incision.

(6) Apex of cone opened after two days.

The first skin incision is about three inches long, and is made, according
to Fenger, in a line parallel to, and about one and one-half inches from the
left costal border, commencing near the middle line (Fig. 145). The fibers
of the rectus muscle are separated, vertically, and the peritoneum opened.
A second incision, three-fourths inch long, is next made parallel to the first,

OPERATIONS UPON THE STOMACH. 211

through skin and fascia, about one inch above the costal margin. A
portion of the anterior wall of the stomach is taken up, near the cardiac
end, and drawn out through the abdominal incision in the form of a cone
(Fig. 146). This cone is prevented from slipping back by four stitches
which attach its base to the cut peritoneal edges of the abdominal wound.
The bridge of skin intervening between the two incisions is raised by blunt
dissection just enough to allow the cone to be passed beneath and fastened
(Fig. 147), after which the skin is completely closed over the first incision

\ '\

Ail'

Fig. 145. — Ssbanajew-Franck Gastrostomy.
Incision lines.

(Fig. 148). The opening of the cone is deferred for two or three days; but
it may be done at once, if necessary. Fig. 149 is a cross section.

PYLORODIOSIS.

This operation consists in enlarging the pyloric outlet of the stomach
by stretching. It was formerly much used for benign and, occasionally,
for malignant strictures of the pylorus.

There are two objections to the technic, the first being the transient
nature of the results obtained. Although immediate relief may be ex-
26

212 INTESTINAL AND GASTRIC OPERATIONS.

perienced after stretching of the pylorus, the reported cases frequently
show a return of the symptoms within a few months or weeks. The second
objection to this operation is the danger of rupturing the duodenum.
Several cases of fatal peritonitis have been attributed to this cause. 1 In re-
cent years stretching of the pylorus has been superseded by more effective
operations, although, in occasional cases of spasm 2 , 3 , or hypertrophy of the
circular fibers of the pylorus 4 , 5 , 6 , 7 , the results yielded are said to have
been good.

There are two methods of stretching the pylorus, known from their
originators as the operations of Loreta and of Hahn.

LORETA'S OPERATION. 8
In his first operations Loreta opened the stomach about three centimeters
from the sphincter, parallel with and about half way between the curvatures.
He then pushed a finger slowly and gradually into the contracted outlet.
This process was continued until it was possible to introduce both index
fingers, one of which was used to steady the pylorus, while the other was
gradually separated from the first. In this manner a very large opening
was effected. Manual dilatation afterwards gave way to the use of instru-
ments, so that in the rare instances where Loreta's operation is now em-
ployed the stretching is done with bougies, sounds, or a uterine dilator.
It is recognized, nevertheless, that the use of instruments for the purpose
of stretching the pyloric sphincter adds a considerable risk to the operation
from the increased danger of tearing the duodenum.
Steps :

(i) Incision into the stomach.

(2) Dilatation of the pylorus.
The gastric incision is best made at right angles to the long axis of the pylo-
rus, at least two inches proximal to the sphincter. This method minimizes
the hemorrhage since the cut is practically parallel to the vessels. Beside

1 Swain. London Lancet, 1891, 1, 87.

2 Carle and Fantino. Arch. f. Klin. Chir., Bd. lvi, Heft 1.

3 Boas. Arch. f. Verdauungskr., 1898, Vol. rv, p. 47.

4 Thayer. Johns Hopkins Hospital Bulletin, 1893, Vol. iv, No. 31.

5 Hirsch. Berl. Klin. Wochenschr., November 9, 1896.
R Lindstrom. Hygeia, September, 1899, p. 267.

7 Kammerer. Annals of Surgery, 1900, Vol. xxxn, p. 18.

8 Loreta. Mem. Accad. d. Sc.d. 1st. di Bologna, 1882, 4, S, iv, 353-375.

Fig. 146. — Ssbanajew-Franck Gastrostomy.
Bridge of skin dissected up. The cone of the stomach is being pulled beneath bridge.

^^^^^^^^■E

Fig. 147. — Ssbanajew-Franck Gastrostomy.

Cone of stomach held in place with forceps. The base of the cone fastened to the peritoneum with

interrupted stitches. These stitches arc only visible in the cross section.

2 ij

Fig. 148.— Ssbanajew-Franck Gastrostomy.
Skin closed over base of cone. Apex of cone opened and sewed to skin.

Fig. 149.— -Ssbanajew-Franck Gastrostomy.

Cross section.

215

OPERATIONS UPON THE STOMACH. 2 1 7

the avoidance of excessive bleeding, there are two other advantages gained
by entering the stomach through a transverse incision, as follows: The
approach to the pylorus is rendered much easier since retraction is only
necessary on the distal side of the wound to expose freely the pyloric out-
let. On the other hand, the ultimate scar formation which follows the
healing of a longitudinal incision must narrow, more or less, the caliber of
the zone involved, a possibility which should be wholly escaped by adopting
the transverse opening. In non-malignant strictures of the pylorus much of
the muscle has been replaced by connective tissue. Stretching of the inelas-
tic scar has been recognized as dangerous, and, for this reason, abandoned.
When pylorodiosis is done for spasm or for hypertrophy of the circular
muscular fibers extreme caution is necessary in the introduction of the
instrument in order to avoid tearing the mucous membrane, with resulting
intractable bleeding. The left hand steadies the pylorus from the outside
while the point of the instrument is delicately engaged with the right. After
the outlet has been opened to slightly above its normal caliber the stomach
is closed with two layers of sutures.

HAHN'S OPERATION. 1

The chief advantage of Hahn's technic seems to be the exemption of
the stomach from incision. This operation should not be done without
gloves, else the nail on the entering finger may injure the peritoneum.

Steps :

(1) Pylorus steadied with left hand.

(2) Pylorus stretched by invagination of anterior wall on finger.
Unless the left hand holds the pylorus and the beginning of the duodenum
it is obviously not possible for the right hand to exert the pressure necessary
for this technic. The success of the method depends upon the muscular
relaxation of that portion of the anterior wall invaginated on the finger. In
case the muscular spasm reaches beyond the immediate vicinity of the
sphincter, a wide margin should be taken from the contracted area. The fin-
ger is gradually pressed backward and to the patient's right, until the tip en-
gages the orifice; it may be necessary to use the little finger for this purpose
when the hole is very small. Steady pressure against the left hand gradually
wedges the finger into the sphincter, when it is quickly substituted for a

1 Hahn. Deuts. Med. Wochenschr., 1891, xvu, p. 913.

2l8

INTESTINAL AND GASTRIC OPERATIONS.

larger finger. Writers who have had experience with Hahn's operation
are agreed that, to get the best after-effects, it is sufficient to introduce two
fingers (Fig. 150).

^ / Fig. 150. — Pylorodiosis, Hahn's Method.

,<J/The right forefinger is wedging a fold of the anterior stomach wall into the pyloric outlet. The left hand
\At;LI \iv ■/ steadies the duodenum.

OPERATIONS FOR NON-MALIGNANT STRICTURE OF THE PYLORUS.
Drainage of the stomach may be accomplished in one of several ways:

(1) Pyloroplasty (Heinecke-Mikulicz) .

(2) Gastroduodenostomy.

Finney's method.
Kocher's method.

(3) Gastroenterostomy.

Posterior method.
Anterior method.
In the discussion of the mechanical indications for these operations pyloro-

OPERATIONS UPON THE STOMACH. 219

plasty and gastroduodenostomy may be considered in the same class, al-
though their clinical indications vary within certain limits. A mode of
procedure adaptable to every case of obstruction of the pylorus has not
been found; the technic must be chosen to meet the condition discovered
at operation. In working upon the stomach of normal animals Cannon
and Blake have demonstrated several new and important facts concerning
the movements of the food in the stomach after various gastrointestinal
operations. Their conclusions are quoted in full: 1

"The stomach is not a passive bag. During digestion the cardiac end
slowly contracts, pressing its contents into the pyloric end. Over the pyloric
end during digestion peristaltic waves are continually running, churning
the food with the gastric juices and forcing the chyme into the intestine.
Observations on the functioning human stomach show that as it empties
it shortens, especially along the greater curvature. Therefore the part of
the stomach lowest when the organ is full or relaxed is not lowest as it
empties. The pylorus then becomes the lowest point. Even if 'gravity
drainage' occurred, the pylorus is the natural outlet so long as the stomach
retains its power of contracting.

"The pressure within the abdomen is approximately atmospheric
pressure. The pressure in any part of the passive alimentary canal depends
on the weight of the overlying abdominal organs. If the canal is inactive,
the food therefore is as if surrounded by water. Gravity cannot act, and
gravity drainage does not occur.

"After an ordinary meal, the peristalsis of the pyloric end of the stomach
makes the contents of this part more fluid than the contents of the cardiac
end. Because peristaltic waves move toward the pylorus, the intra-
gastric pressure is three or four times greater at the pylorus than in the
cardiac end. Observations on large cats with gastroenterostomy openings
of various sizes at various parts of the stomach showed that unless the open-
ing, or stoma, was in the antrum — i. e., close to the pylorus — the food, even
when fluid, was pushed through the pylorus rather than through the stoma.

"With peristalsis only in the pyloric end of the stomach, with the intra-
gastric pressure much greater at the pylorus than elsewhere in the stomach,
and with the food in the pyloric end normally more fluid than that in the

1 Cannon and Blake. Annals of Surgery, May, 1905.
27

220 INTESTINAL AND GASTRIC OPERATIONS.

cardiac end, the food is forced into the intestine through the pylorus and not
through the artifical opening, when both ways are offered.

"Circulation of the food through the pylorus to the duodenum and
back to the stomach through the anastomosis has been repeatedly observed,
but it was not followed by the clinical symptoms of 'vicious circle.' The
circulation was observed best when the stomach was very full. The
stretching of the stomach separates the lips of the stoma and draws the
intestinal wall into line with the gastric wall. The openings into the
intestine at the stoma become mere slits, and act like valves, permitting
the entrance, but preventing the exit, of the food.

"The clinical symptoms of the 'vicious circle' have been observed in
animals in which a kink of the intestine has been found just distal to the
anastomosis. Kinks at this point cannot be straightened by peristaltic activ-
ity because the circular fibers of the intestine are cut at the nearby stoma.

"It is important that food be mixed with the secretions poured into
the duodenum. These are highly effective in digestion, and also neu-
tralize the acid chyme. If food leaves the stomach by the stoma, it is
not mixed with these secretions. Jejunal ulcers after gastroenterostomy
may be due to the presence of acid in the region in which inorganic acid is
not normally found.

"From the above considerations, it was concluded that the stoma
should be large and as near to the pylorus as possible; that the circulation
of the food be rendered less probable by avoidance of overeating, and that,
so far as possible, kinks be obviated by attaching a narrow band of the distal
gut to the stomach for several centimeters beyond the stoma, thus permitting
peristalsis to become an effective force.

"The probability of a circulation of the food whenever the pylorus
is left open, the non-mixture of the food with the digestive and neutralizing
fluids in the duodenum, and the ever-present danger from kinks in gastro-
enterostomy, make the operation not an ideal one.

"In pyloroplasty (preferably the Finney operation) these objections
are avoided. And a too rapid exit of the food through the pylorus is pre-
vented by rhythmic segmentation of the food in the duodenum, an activity
which in part replaces the function of the pylorus, and also mixes the food
with the pancreatic juice and the bile. "

OPERATIONS UPON THE STOMACH. 221

PYLOROPLASTY.

(Heinecke '^Mikulicz 2 .)

This operation consists in enlarging the pyloric outlet of the stomach by
means of incision and suture. It is done in certain cases where the caliber
of the opening has become contracted as a result of benign disease, usually
from scars following gastric ulcer. W. J. Mayo 3 states that, although the
operation is attended with little risk, the technic has several deficiencies.
It enlarges the caliber of the opening upward as well as downward in the
line of drainage, while the extent to which this enlargement can be carried
out is limited. Mayo has found that extensive adhesions commonly
follow this operation, and in this manner the pyloric opening becomes
permanently fixed at a high level. In cases where the muscle-fibers of the
stomach are not capable of carrying out the normal peristaltic action,
considerable difficulty may attend the effort to lift the food up through
the highly-placed outlet. Mayo tried to overcome the difficulty just
mentioned by fastening the pylorus in a lower position, but he does not
advise the adoption of this method. Robson and Moynihan 4 do not favor
the general use of this technic but reserve it for "string-like narrowing, or
in spasm of the pylorus."

Steps :

(i) Exposure of pylorus, application of clamps.

(2) Horseshoe incision for division of stricture.

(3) Conversion of horseshoe into vertical incision.

(4) Opening sewed together in new position in two layers.

The abdomen is opened in the median line, and the pylorus exposed.
After carefully walling off the field of operation with gauze, the pylorus
is brought forward. In cases where the pylorus is held down by adhesions,
this operation is said to be contraindicated. The clamps are applied as
follows: On the stomach, the blades are placed directly across the pyloric
portion, about three inches proximal to the stricture. The lower jaw of

1 Heinecke. Ref. by Fronmuller. " Operation der Pylorusstenose," Inaug. Dissert., Furth,
1886.

2 Mikulicz. Archiv fur Klin. Chir., 1887, Bd. 37, S. 79.

3 Mayo, W. J. Annals of Surgery, November, 1905.

1 Robson and Moynihan. "The Surgical Treatment of Diseases of the Stomach," 1904, p. 265.

222 INTESTINAL AND GASTRIC OPERATIONS.

the clamp penetrates the gastrocolic omentum and lies beneath the stomach,
in the lesser peritoneal cavity. On the duodenum, the clamp is placed
about three inches distal to the stricture, at right angles to the long axis
of the intestine. Mikulicz's incision is made parallel to the long axis of
the pylorus and the duodenum, having the shape of a horseshoe, the arms
of which extend over the stomach and the duodenum for about one inch
on either side of the stricture (Fig. 151). Richardson 1 modifies this opera-
tion, in the presence of a dense stricture, by excising the thickened mass
before uniting the cut edges. The redundant mucous membrane is cut
away, as shown in Fig. 152. The second part of the operation consists
in seizing the upper and the lower lips of the incision at their middle points.
By drawing one edge upward and the other downward the incision is
changed from a horseshoe curve into an irregularly vertical line. While
held taut, either with guide stitches or with forceps in this new position,
the cut is sewed up in two layers, as usual.

GASTRODUODENOSTOMY.

This operation consists in establishing an artificial outlet between the
stomach and the upper portion of the duodenum. Kocher 2 first described
the operation of gastroduodenostomy in 1891 when be joined the duodenum
to the posterior wall of the stomach after resection of the pylorus. This
gastroduodenostomy is not a lateral but an end-to-side technic. In 1892
Jaboulay 3 reported the first lateral anastomosis between the stomach and
the duodenum. This is quite similar to the present operation, although
many difficulties have been removed by later technical improvements.
Henle, 4 Villard, 5 and Tixier 6 have since published cases and experimental
work concerning gastroduodenostomy. These writers allude to freeing
the duodenum to bring it into contact with the stomach, but give no par-
ticulars, other than to say that the technic is easy. As it is to this feature
that the success of the operation is due, Jaboulay's method was compara-
tively little used until the anatomical question had been solved by later

1 Richardson, M. H. Boston Med. and Surg. Journal, November 30, 1899.

2 Kocher. Archiv fur Klin. Chir., 1891, Bd. 42, p. 542.

3 Jaboulay. Archiv. prov. de Chir., 1892, Vol. 1, p. 551.

4 Henle. Cent, fur Chir., 1898, Vol. xxv, p. 753.

5 Villard. Lyon Medical, 1900, Vol. xcm, p. 522.

6 Tixier. Ibid., p. 53.

]

-a

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is.

c
3

3
3

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>.'■■'

223

OPERATIONS UPON THE STOMACH. 225

observers. In 1902 Finney 1 described his operation, and gave the first
account of a method of mobilizing the upper part of the duodenum. In
the following year Kocher 2 published a similar scheme for loosening this
portion of the small intestine as a preliminary step to his modification of
Jaboulay's operation. The two methods of performing gastroduoden-
ostomy to be described are known respectively as :

(1) Finney's operation.

(2) Kocher's operation.

FINNEY'S OPERATION.

This operation has for its purpose the enlargement of the pyloric outlet
of the stomach. The incision is practically the same as that made for the
Heinecke-Mikulicz pyloroplasty, the method of sewing together the wound
being the distinguishing factor of Finney's technic. Properly the operation
is a pyloroplasty, but it is classed here as a gastroduodenostomy in order
to save space in the description of the mobilization of the duodenum, a
step which it has in common with gastroduodenostomy. The researches
of Cannon and Blake 3 showed that the best drainage of the stomach is
obtained by attaching the intestine as near as possible to the pylorus.
Finney's technic was recommended by these writers for this purpose; but
there are several conditions which make the operation difficult or impossible.
"Extensive disease, adhesions, a short gastrohepatic omentum, especially
in the presence of scar tissue," should be regarded as contraindications of
this operation (Mayo 4 ). On the other hand, Finney ° states that in three
years' experience he has found no pyloric obstruction in which this opera-
tion could not be used.

In his original communication Finney made no mention of clamps,
and his method has been modified by the author 6 in this respect, by animal
experimentation, as given below:

1 Finney. Bulletin Johns Hopkins Hospital, July, 1902.

2 Kocher. Zeitsch. fiir Chir., January 10, 1903, No. 2, p. 33.

3 Cannon and Blake. Loc. cit.
i Mayo, W. J. Loc. cit.

c Finney. Surgery, Gynaecology and Obstetrics, Chicago, Febuary, 1906.
6 Gould, A. H. Boston Med. and Surg. Journal, JanuaryJs, 1905.

226 INTESTINAL AND GASTRIC OPERATIONS.

Fig. 153. — A View of the Relations of the Posterior Abdominal Wall. (Sobotta.)
The anterior abdominal wall and the anterior portion of the diaphragm have been removed by a
frontal section. The stomach has been taken away between the cardia and the pylorus, exposing the lesser
peritoneal cavity. The liver has been wholly removed. The parietal peritoneum has been denuded
from the kidneys, part of the duodenum, the large vessels, and the musculature. The section shows the
line of attachment of the mesocolon. Note relations of the duodenum.

Steps :

(1) Mobilization of the duodenum.

(2) Clamps.

(3) First seromuscular suture.

(4) Opening of stomach and duodenum.

(5) Inner through-and-through continuous suture.

(6) Clamps removed.

(7) Outer seromuscular suture.

A portion of Kocher's original article is quoted below which describes the
mobilization of the duodenum:

"In intrauterine life the duodenum hangs free in the abdominal cavity
(Merkel), and in childhood it still possesses considerable mobility. In
later life its right side is directed toward, and becomes adherent to, the pos-
terior abdominal wall, so that its anterior surface only is covered by the
parietal peritoneum of the posterior wall of the abdomen. Even in the
adult it may readily be demonstrated that the duodenum can be compara-
tively easily freed again, so that, as in the fetus, its descending portion and
inferior flexure may be rendered movable and brought forward.

"To free the duodenum in this way it is necessary to divide the parietal
peritoneum to the right of the descending part of the duodenum. The
membrane is divided vertically over the front of the right kidney, a little
to the left of the descending limb of the hepatic flexure of the colon. The
parietal peritoneum stretches, in this situation, from the front of the right
kidney to the colon, forming the upper layer of the transverse mesocolon.
If the finger be passed upward along the second part of the duodenum, in
front of the peritoneum covering the kidney, it will enter the foramen of
Winslow, above the superior flexure of the duodenum and behind the free
border of the gastrohepatic omentum, which contains the portal vein, the
hepatic artery, and bile duct.

"We recommend that this delicate layer of parietal peritoneum be

right suprarenal gland

hepatoduodenal hepatic inferior . ,

ligament vein vena cava pylorus cardia gastropancreatic fold parietal

/ , , , peritoneum

xternal
iac art.

spermatic cord

umbilical i

Fig. 153

/0&^O>

o
o

OPERATIONS UPON THE STOMACH. 227

divided with the knife two finger-breadths to the right of and parallel to the
second part of the duodenum, so that the peritoneum covering the anterior
surface of the duodenum may not be injured, as would be the case were
the peritoneum simply torn through.

"If the divided peritoneum adjacent to the second part of the duodenum
be grasped and pulled forward, the fingers can then be introduced behind
the duodenum so as to raise it from the vertebral column, the vena cava,
and the aorta. If the peritoneum which descends toward the colon be also
divided, the inferior duodenal flexure can also be raised up, not a single vessel
of any size being injured. The head of the pancreas is raised up along
with the duodenum so that the concave border of the latter, which must
not be separated, becomes so movable that it offers no hindrance to the
raising up of the duodenum.

"By this procedure the muscular coat of the posterior surface of the
duodenum is not laid bare, being covered by a layer of connective tissue.

" By the above manipulations the second part of the duodenum is rendered
so movable that it can be easily brought up to the anterior surface of the
pyloric portion of the stomach above the greater curvature.

"The extent to which the duodenum can be freed depends on the arrange-
ment of the vessels. The right gastroepiploic artery (the main branch of
the gastroduodenal artery) gives off important branches which pass from
the left concave border of the duodenum across its transverse (third) part
to the transverse colon. These vessels, which lie behind the upper layer
of the gastrocolic ligament, do not interfere to any extent with the raising
of the duodenum from the vertebral column. If the colon be thrown upward
the large colic artery will be seen crossing in front of the duodenum and
then running along its lower margin to reach the ascending colon and the
hepatic flexure. While these vessels are not so easily displaced to the
left as the branches which go to the colon from the right gastroepiploic
vessels, they nevertheless do not prevent the inferior flexure of the duodenum
from being sufficiently freed to allow the whole of its descending portion
to be raised up from the vertebral column into a convenient position for
suturing. The duodenum and the stomach, before being opened, must
be grasped between the fingers above and below the intended line of suture

so that escape of contents may be prevented.
28

228

INTESTINAL AND GASTRIC OPERATIONS.

"The part of the duodenum that can be least freed is the superior
flexure, because to it is attached the gastrohepatic omentum containing
the important vessels already mentioned. This ligament, and its prolon-
gation downward along the concave border of the duodenum on to the head

Fig. 154. — Mobilization op the Second Portion of the Duodenum. (Finney-Kocher Method.)
Note vertical peritoneal incision parallel to and to the right of the second portion of the duodenum.
The duodenum is being shelled out with the finger. Also note the dotted line on the edge of the lesser
omentum. A superficial cut through the omentum at this point allows the pylorus to drop down, thus
assisting in the mobilization of the duodenum.

of the pancreas, forms an axis around which the descending limb and
inferior flexure of the duodenum can be rotated forwards. The lower
end of the axis of rotation is determined by the vessels which descend
vertically across the terminal portion of the duodenum, and which do not

OPERATIONS UPON THE STOMACH.

22g

interfere with the raising up of the inferior flexure and the adjacent
portion of the third part of the duodenum. "

As an addition to the above procedure Finney suggests the division
of the suspensory ligament of the pylorus which anchors the upper flexure
of the duodenum whenever it is difficult to draw the pyloric angle down-
ward to a sufficient degree to allow the anastomosis to be carried out.
After the division of this peritoneal fold the pylorus can be brought down

Fig. 155. — Finney's Gastroduodenostoiiy.
Note application of clamps. On the stomach they are placed parallel with the greater curvature,
thus controlling the hemorrhage from the vessels which are seen crossing the line of the future incision.
Inner jaws of both clamps touch at the pyloric angle. When the handles are brought together, the
pyloric angle (P) is put on the stretch. It can be seen that the use of guides is unnecessary to make
the folds lie side by side.

within easy reach (Fig. 154). The length of duodenum which it is re-
quired to mobilize for this operation is not constant, but it will usually
be found necessary to free two or three inches before the duodenum will
lie easily beside the stomach. When the duodenum is sufficiently freed
clamps are applied (Fig. 155). On the duodenum a fold of bowel about
two and one-half inches long is taken up, longitudinally, and the clamp
pushed up until the inner jaw rests against the pyloric sphincter. On the

230

INTESTINAL AND GASTRIC OPERATIONS.

stomach the clamp is placed in a similar manner, the point of the inner
jaw touching that of the duodenal clamp at the pylorus. The ends of the
clamps are not freed, but grasp the bowel half an inch below the free edge.
This places the clamps at right angles to the blood-vessels both of the
stomach and of the duodenum. When the handles of the two clamps are
brought together, the pyloric angle is put on the stretch, thus controlling
hemorrhage, and preventing leakage from this inaccessible point. If the

Fig. 156. — Finney's Gastroduodenostomy.
Clamps are now side by side. Folds approximated by a continuous seromuscular stitch. Stomach
incised to mucous membrane; duodenum then opened freely to pyloric angle. Scissors now cutting
out redundant mucous membrane along dotted line. The next step is to sew x to x, beginning at the
pyloric end of the tongue.

clamps are placed in the manner recommended above, the remainder of
the operation will practically amount to a repetition of the gastroenter-
ostomy technic, described later. The folds are fastened together, as they
lie side by side, by the usual outer seromuscular stitch. This stitch starts
at the pyloric angle to make sure that this point is placed at the apex of the
tongue to be cut out later. The incisions into the bowel and the stomach
are like those of a gastroenterostomy, except that they are joined at one

OPERATIONS UPON THE STOMACH.

231

end, an addition which is made possible by the continuity of the two organs.
The stomach incision is carried down until the mucous membrane pouches
between the cut muscular walls. The stomach incision is then left, and
the duodenum opened, until the mucous membrane is met at the pyloric
angle (Fig. 156). The pouching mucous membrane is removed from the
stomach by cutting with scissors close to one muscular edge, returning on
the other side. The completed incision leaves a tongue-like process made
up of half stomach and half intestinal walls. The two edges of the tongue
are next sewed together with a continuous through-and-through chromic
stitch, which starts at the apex of the tongue and goes across the cut to
the base (Fig. 157). At this point the suture is interrupted with a tie,

Fig. 157. — Finney's Gastroduodenostomy.

Tongue (t) now closed over by continuous stitch, which has turned corner to finish front of suture,

bringing X to X. This line of suture is finally buried in by a seromuscular stitch.

after which the suture is continued around over the front and tied at the
pyloric angle. It is necessary to loosen the clamps before placing the last
few stitches of this suture, since this area is under too great tension to allow
the edges to be brought together. Finney 1 closes in the front of the joint

\Finney. Surgery, Gynaecology and Obstetrics, February, 1906.

2 3 2

INTESTINAL AND GASTRIC OPERATIONS.

with a series of mattress stitches placed before the incision is made. He
finds this method to be preferred over the running stitch for closing in
the front of the joint. The clamps are, finally, removed altogether and
the suture buried in with a continuous seromuscular suture. If this opera-

Fig. 158. — Finney's Gastroduodenostomy.
Cross section of pylorus and duodenum before operation, for comparison with Fig. 159.

Fig. 159. — Finney's Gastroduodenostomy.
Cross section after operation, showing increase in caliber of pylorus; caliber increased over Fig. 158

by length of sewed edges.

tion is done without clamps, or if they are placed across the pylorus,
the tongue, referred to above, will protrude between the edges of the
wound and will thus hinder the suture over the front. If the clamps
are placed as recommended here, this tongue will cause no more trouble

OPERATIONS UPON THE STOMACH. 233

than is experienced from the lower cut edges of a gastroenterostomy. As
to the length of the incisions into the stomach and the duodenum, the
usual size of the pyloric outlet should be fully restored, with a slight over-
correction to allow for the possibility of a future contraction. 1 The open-
ings made in the early cases, where this technic was followed, were usually
larger than necessary, and have occasionally been followed by unpleasant
symptoms, possibly due to the regurgitation of bile into the stomach.
(Figs. 158 and 159 are cross sections.)

The actual mechanical result of carrying the incision far down over
the duodenum is not to increase proportionately the caliber of the outlet,
for this can never be made larger than the diameter of the duodenum;
but it converts the attached portion of the duodenum into a sort of extension
of the pyloric portion of the stomach, leaving the duodenal outlet pointing
downward at a right angle with the long axis of the stomach.

KOCHER'S GASTRODUODENOSTOMY.

This operation is a lateral anastomosis between the pyloric portion
of the stomach and the second or descending portion of the duodenum.
Kocher has found that the operation is contraindicated when adhesions
are present between the duodenum and the under surface of the liver.

Steps :

"(i) Mobilization of the duodenum.

(2) Clamps.

(3) Lateral anastomosis.
Kocher explains the technic as follows :

"After what has been said regarding the freeing of the duodenum,
the following will suffice to describe our method of performing gastro-
duodenostomy. The most suitable incision is one similar to that which
we recommend for exposing the gall bladder, — viz., an oblique incision
two finger-breadths below and parallel to the right costal margin, beginning
at the middle line. After dividing the skin and fascia the rectus muscle
is cut through as far as the broad abdominal muscles. The posterior layer
of the rectal sheath, the fascia trans versalis, and the peritoneum are divided.
In muscular subjects the transversalis muscle is split parallel to its fibers,

1 Finney makes the opening about 10 cm.

234 INTESTINAL AND GASTRIC OPERATIONS.

which are then firmly drawn apart. Should any adhesions exist between
the gall bladder and the colon they must be divided. The liver is drawn
upward, the stomach to the left, and the transverse colon and the descend-
ing limb of the hepatic flexure downward. The duodenum is then brought
into view and its outer border is clearly defined. A pad of gauze is placed
against the under surface of the liver, and the latter is then drawn well
upward with a suitable retractor. Gauze compresses are also employed
to push aside the stomach and colon.

"The delicate layer of parietal peritoneum covering the kidney is divided
vertically one and one-half inches external to the second part of the duo-
denum, and the incision is then continued vertically downward through
the upper layer of the transverse mesocolon (which is held on the stretch)
as far as the large branches of the vessels. The fingers are then introduced
behind the left edge of the incision through the peritoneum, and the duode-
num is separated from the vertebral column, the vena cava, and the aorta,
until it can be brought forward and pressed against the pyloric portion of
the stomach, which, in its turn, is compressed against the left edge of the
wound in the abdominal wall so as to shut off the general cavity of the stom-
ach and prevent escape of its contents. Both stomach and duodenum are
now compressed above and below between the fingers of an assistant, and the
lateral anastomosis is effected in the usual manner by two rows of sutures. "

Kocher gives no account of the technic for placing the clamps. The
point of application of the clamps should be as near to the pylorus as the
local conditions will allow. On the stomach the clamp is placed parallel
to, and about half an inch from the greater curvature. On the duodenum
the clamp is placed on the free border, parallel to the long axis of the
intestine (Fig. 160). The remainder of the technic is that of the ordinary
lateral intestinal anastomosis.

Krause's clamps are especially useful for this operation, since the full
curve of the blades will make their application easier in cases where the
field of operation is difficult to approach.

C. A. Porter 1 has successfully anastomosed the duodenum to the lesser
curvature of the stomach, by a modification of Kocher's technic, in a case
where the greater curvature was involved.

1 C. A. Porter. Unreported case.

Fig. 160. — Kocher's Gastroduodenostomy.

The duodenum has been loosened and drawn inward. Krause's clamps are useful here on account of

their full curve. Dotted line shows site of the anastomosis.

^35

OPERATIONS UPON THE STOMACH. 237

GASTROENTEROSTOMY.

(1) Posterior method.

(2) Anterior method.

This operation consists in the establishment of an artificial opening
between the stomach and some part of the intestinal canal. The use of
the term is now practically limited to the anastomosis of the stomach with
the jejunum. It is hardly fair to quote opinions upon the subject of gastro-
enterostomy, since this operation is still the center of experiment and
discussion. Without committing any surgeon to the advocacy of this
technic, it may be said that its elaboration has been largely due to the work
of Wolfler, von Hacker, Peterson, the Mayos, Moynihan, Littlewood, Rob-
son, Munro, and others.

POSTERIOR GASTROENTEROSTOMY.

(Von Hacker. 1 )

Steps :

(1) Great omentum and transverse colon lifted out of the abdomen

to expose under surface of mesocolon.

(2) Mesocolon opened over lowermost point of stomach, and

posterior wall of stomach pushed through opening with
fingers of left hand.

(3) Clamps, stomach and jejunum; walling off.

(4) First half of seromuscular stitch.

(5) Incisions into stomach and jejunum.

(6) Inner through-and-through catgut stitch.

(7) Clamps loosened, one removed.

(8) Second half of seromuscular stich, over front; second clamp

removed.

(9) Cut edges of mesocolon sewed to stomach.

The abdomen is opened about three-fourths inch to the right of the middle
line, through the rectus muscle. The stomach is brought forward out of
its bed, lifted, with the transverse colon and the greater omentum, out of
the abdomen, and turned over the upper angle of the abdominal incision.

1 Von Hacker. Wien. Klin. Wochenschr., 1890,10,348; Verhandl. d. Deutsch. Gesellsch.
fur Chir., 1885.

238 INTESTINAL AND GASTRIC OPERATIONS.

Fig. 161. — Front view of the relations of the great omentum and the stomach. (Sobotta.)
Fig. 162. — The great omentum turned up exposing the small intestines. The transverse colon is undis-
turbed. (Sobotta.)
Fig. 163. — Transverse colon lifted up over the thorax. Small intestine falling to one side, disclosing the

duodenojejunal flexure, with the ligament of Treitz. Note the colica media artery. (Sobotta.)
Fig. 164. — The small intestine cut off between the beginning of the jejunum and the cecum. Note the

cut mesenteric edges of the small intestine, the vessels, and the large intestine. (Sobotta.)

This exposes the under surface of the transverse mesocolon, in which
are seen ramifying the vascular arches of the colica media artery (Figs.
161, 162, 163, and 164). The fingers of the left hand now grasp the point
on the greater curvature which is lowermost when the stomach is in its
normal relations within the abdomen. By pressing firmly upward on the
posterior wall of the stomach with the fingers of the left hand the meso-
colon is made to bulge over the point at which the anastomosis is to be made.
A bloodless spot is chosen, and a small incision made through the mesocolon,
in a direction at right angles to that of the long axis of the transverse colon.
Moynihan 1 finds it of advantage to seize a small portion of the mesocolon
with forceps, at a point near the spot selected for opening, in order to draw
the mesocolon away from the posterior wall of the stomach while the incision
is being made. Some difficulty is occasionally experienced in gaining en-
trance into the lesser peritoneal cavity when adhesions are present between
the mesocolon and the stomach. Under these circumstances the mesocolon
should be separated by blunt dissection from the stomach for a sufficient
distance to allow room for the anastomosis. When this separation cannot be
done with safety, the anastomosis must be made on the anterior wall. The
fingers are now slipped into the lesser sac, and the incision gradually en-
larged, by tearing and stretching, to an opening about three inches in length.
Occasionally it may be necessary to tie a small artery at the edge of the
mesocolic incision. Continued pressure with the left hand at the point
grasped earlier in the operation will present the posterior wall of the stomach
at the window in the mesocolon, where the stomach is grasped and pulled
well through. Moynihan's line of incision is made obliquely from above
downward and to the right, on an imaginary line drawn between two points
which are, respectively, the middle of the dome, and the lowermost point
on the greater curvature of the stomach. This lowermost point is, however,

1 Moynihan. The Practitioner, London, 1904, LXxn, p. 251.

gall-bladder

xiphoid proc. of sternum costa[ arcn
falciform lig. of liver > /,

round ligament of liver\ \ j /I

I //

folds

of epigastric

artery

lateral
umbilical
ligament

Fig. 161

hepatic /
flexure ,

of colon

splenic flexurt
of colon

coecum

FlG. 162

duodena

jejunal

recess

duodeno-
jejunal
flexure

splenic
flexure

of ColOi

vermiform process '

rectum

urinary bladder

Fig. 163

sigmoid colon

* A

.«*-** <►.

great omentum .

ff'f I ^jfm

transverse colon

hepatic
flexure --''
of colon

splenic flexur
jp- of colon

ascending
- portion
of duodenum

root of
f" mesentery

~"|j- - - -L _ __ descending
P p mesocolon

ileum

inferior ileocecal foisa vermiform process urinary bladder rectum

Fig. 164

OPERATIONS UPON THE STOMACH.

2 39

a variable one, according to whether the stomach is at rest or in motion
(Cannon and Blake). 1 In the resting stomach the lowest point is found
almost exactly beneath the angle formed by the bending of the vertical
portion of the lesser curvature to the right to become the upper border of the

Fig. 165. — Posterior Gastroenterostomy.
The clamps have been applied about three inches distal to the duodenojejunal flexure. The blades
of the stomach clamp have been placed obliquely (Moynihan), while the handles point to the patient's
right shoulder (Mayo, Munro). (Drawn according to suggestions from W. J. Mayo.)

pyloric portion. 2 This point is placed at a distance of from two to three
inches to the left of the pyloric sphincter. A fold of the posterior wall is
picked up on Moynihan's line with two pairs of forceps, the lower end of

1 Cannon and Blake. Loc. cit.

2 Mayo, W. J. Annals of Surgery, November, 1905.

240 INTESTINAL AND GASTRIC OPERATIONS.

which fold includes a small portion of the greater curvature (Fig. 165).
When the clamp is applied to this fold, the tips of the blades point to the
outer side of the patient's left hip, and the handles to his right shoulder
(W. J. Mayo). 1 Mayo carries the gastric incision to the very bottom of the
stomach, as seen at rest, thus necessitating a separation of the greater
omentum from the posterior wall of the stomach for a short distance at
this point. The experiments of Cannon and Blake, alluded to above, have
shown that the lowest point of the stomach is not a fixed one, but changes
rapidly as the peristaltic waves pass along from the fundus toward the
pylorus.

In view of these valuable experiments, it seems unnecessary to carry
the incision to the very bottom of the resting stomach. On the other hand,
in performing a gastroenterostomy, it is desirable to leave the beginning of
the jejunum and the posterior wall of the stomach as nearly as possible
in their natural relations, after completing the anastomosis, — an anatomical
advantage which is distinctly offered by Moynihan's line of incision. In
cases where an enteroenterostomy is done, between the proximal and the
distal jejunal coils (Braun 2 and Jaboulay 3 ), the incision should be made
parallel to the greater curvature, as the natural anatomical relations will
be changed by the downward traction of the anastomosis below. The
identification of the beginning of the jejunum is accomplished by sweeping
the finger along the under surface of the attachment of the transverse meso-
colon to the posterior abdominal wall. The intestine will be found just
to the left of the spine, as seen in the anatomical plates, whence it is hooked
up on the finger, and brought out of the abdomen. The point chosen for
the jejunal opening is, necessarily, variable. While the stomach lies
outside of the abdomen, it is possible to perform the anastomosis close to the
duodenojejunal flexure, as recommended by Peterson. 4 Before attaching
the jejunum, however, to the stomach, an examination should be made to
determine the position of the greater curvature, while lying at rest, within
the abdomen. If the loop of jejunum be too short (after the stomach is
replaced), a sharp downward kink will follow at the duodenojejunal flexure,

1 Mayo, W.J. Ibid.

2 Braun. Cent, fiir Chir., 1892, Vol. xrx, p. 102.

3 Jaboulay. Archiv prov. de Chir., T. 1, No. 1, p. 1.

4 Peterson. Beitrage zur Klin. Chir., xxix, 1900, 1901, p. 597.

OPERATIONS UPON THE STOMACH. 24 1

which may cause pain or obstruction. The jejunum is now seized with
the left hand, about four or five inches from the duodenojejunal flexure,
and put on the stretch, by pulling upward and to the right (Moynihan). 1
The clamp then grasps a fold on the free border approximately three inches
in length, the nearest point of which fold is three or four inches from the
beginning of the jejunum. The handles of the two clamps are brought
side by side, and the transverse colon, great omentum, and the portions of
the stomach and the jejunum not included in the clamps are returned into
the abdomen. The field of operation is walled off from the abdomen as
follows : A small sponge is tucked between the coils, and around and under
the clamps is wound a handkerchief gauze; over all is laid a dry towel.
A continuous seromuscular stitch is first introduced, which begins at the
left and ends at the right extremity of the clamped folds, the operator
standing on the patient's right. A curved needle is useful for the first
layer of the sutures. The thread is left long at the right end of the first
seromuscular suture, to be used later in closing in the front of the joint.
The length of this outer layer of stitches should be at least three inches,
depending upon the size of the stoma desired. Incisions are now made
into the stomach and the jejunum with a knife, about one-fourth inch to
either side of the first seromuscular stitch. As the cuts are made, the
serous and the muscular coats retract, and the mucous layer pouts into
the incision. Care should be taken to cut straight toward the center of the
gut lumen in order to avoid dissecting the submucosa from the mucosa.
The ellipse of mucous membrane protruding into the incision is cut away
with scissors, following the edge of retracted muscle (Fig. 156). By
pulling the mucous membrane taut with forceps, and taking short, rapid
bites with the scissors, 2 a clean-cut edge of mucous membrane will result,
which does not retract. Moynihan 3 advises dissecting the muscle free
from the underlying layer, and preventing the retraction of the latter
by miniature vulsella forceps. From an experimental point of view it
would seem undesirable to trim away an excessive amount of mucous mem-
brane, since the object of the trimming is to give a clean-cut edge for sewing,

1 Moynihan. Loc. cit.

2 Littlewood. London Lancet, November 3, 1900, p. 1276.

3 Moynihan. Loc. cit.

242

INTESTINAL AND GASTRIC OPERATIONS.

and to avoid the possibility of obstruction by valve formation of the redun-
dant tissue. On the other hand, if the trimming is carried to excess
the mucous membrane will be under great tension after the suture is
completed, thus resulting in a wide ulcer, which must delay the repair.
The cut edges of the intestine and the stomach are now united with a
continuous through- and-through suture of No. o chromic gut. It is cus-
tomary to begin this stitch at one angle of the wound, and sew straight

Fig. 166. — Posterior Gastroenterostomy.
The stomach and the jejunum have been opened and the inner layer of through-and -through sutures
begun, one corner having just been turned. Note that the field has been walled off with a towel, while
a small sponge has been slipped between the two clamps. Beneath the towel has been wound a handker-
chief gauze.

across the base, around the second angle, and over the front. There is
a distinct advantage, however, as pointed out previously by the author,
in turning both corners without stopping, to avoid, as far as possible, all
danger of leakage. The inner stitch is, therefore, begun in the middle of
the base line and tied in the middle of the thread. From the first knot the
suture goes outward toward each corner, piercing all coats, over and over.
The first corner is reached and just turned, and here the thread is tied, and

OPERATIONS UPON THE STOMACH.

243

left long. After this, the suture begins with the long end left at the first
knot, and goes outward to the second corner, which it turns, and, after
crossing over the front, is tied to the end left near the first corner. This
method avoids tying the last knot deep in the angle of the wound (Fig. 116).
As no leakage can now occur, the clamps are unfastened and one en-
tirely removed, while the other clamp is left in place with the jaws open, as

Fig. 167. — Posterior Gastroenterostomy.
The gastroenterostomy has been practically completed, although the front has not yet been wholly
closed in by the seromuscular stitch. The clamp has been loosened but not removed (Munro). The
edges of the mesocolic opening have been sewed to the stomach with interrupted stitches.

recommended by Munro, 1 to prevent the anastomosis from sagging back
into the abdomen (Fig. 167). After loosening the clamps, it may be found
that the bleeding has not been entirely controlled by the through-and-
through suture, in which case this opportunity is taken to make the wound
perfectly dry before going on. The suture line should now be cleaned

1 Quoted by Scudder. Annals of Surgery, September, 1904.
3°

244 INTESTINAL AND GASTRIC OPERATIONS.

before finishing the second line of stitches. This is best done by gentle
washing with sterile salt solution. Gauze should not be used for this
purpose on account of its abrading effect upon the peritoneum, with its
dangers of subsequent adhesions. After washing the suture line, the
towel which walls off the operative field is removed, thus exposing the clean
gauze beneath. The front is finally closed in with a seromuscular stitch,
starting from the long end left on the first outside stitch. Hadra 1 advises
suspension of the loop to the stomach, on either side of the anastomosis,
to prevent kink formation at this point.

The stomach, transverse colon, and the omentum, which have been
replaced within the abdomen, are now withdrawn, and the edges of the
mesocolic opening are fastened to the posterior gastric wall, around the
anastomosis, with two or three interrupted stitches. This prevents hernia of
the small intestine into the lesser peritoneal cavity. When a long proximal
jejunal coil is used, it is wise to add a jejunojejunostomy between the proxi-
mal and the distal coils in order to eliminate, as far as possible, the danger of
circular vomiting. Under these circumstances the gastric anastomosis must
be at least ten inches distal to the beginning of the jejunum, in order to allow
sufficient room for the lateral intestinal suture to be done without running
the danger of leakage from the subsequent tension on the stitches.
Fig. 1 68 shows a cross section explanatory both of the posterior and
of the anterior gastroenterostomies.

In his discussion of the relative merits of the anterior and the posterior
methods of gastroenterostomy W. J. Mayo 2 speaks as follows :

"For benign disease the posterior operation is the one of choice. It is
applied at a higher point on the jejunum, and is unattended with the risk
pertaining to the loop which must surround the transverse colon. That
this loop is of dangerous import is shown by two of our secondary opera-
tions, in one of which a number of feet of small intestine travelled through
the noose, and, in the second, death was directly traced to adhesion and
obstruction of the transverse colon. The length of this loop is from sixteen
to twenty inches, a disadvantage when one considers the proportionately
high value of the upper jejunum in digestion and absorption. The anterior

1 Hadra. Berl. Klin. Wochenschr., 1892, No. 4, p. 75.
3 Mayo. Loc. cit.

OPERATIONS UPON THE STOMACH.

2 45

operation has some few indications. In cancer the disturbance is less,
and, as the gastric juice has little acid, the patient cannot be expected to
live long enough to develop a secondary jejunal ulcer. The anterior

Fig. 168. — Gastroenterostomy. Cross Section.
Two coils attached to show anterior and posterior methods. The section of the anterior gastro-
enterostomy has been made at the point where the great omentum passes off to the side of the mesentery
of the jejunum.

operation is more liable to be followed by contraction on account of the
traction weight of the attached jejunum, a diverticulum formation taking
place which is followed later by contraction. This happens most fre-

246 INTESTINAL AND GASTRIC OPERATIONS.

quently after the button, as the line of union is narrow and it has less of a
grasp on the tissues. Contraction, however, is liable to occur after any
form of operation, especially if the pylorus is unobstructed. With an open
pylorus nature tends to close the opening, no matter what the form of
operation; but the shorter the loop the less the probability of contraction,
and in the operations without a loop we would not consider it a serious
question. We have seen a reduction of one-half take place three and five
months, respectively, after a Moynihan operation on a nine-inch loop."

In "Annals of Surgery" for April, 1906, W. J. Mayo describes a modifi-
cation of the method of attaching the jejunum to the posterior wall of the
stomach. The gastric incision begins at a point one inch above the greater
curvature, on a continuation of a line passing through the vertical portion
of the lesser curvature. The incision ends at the bottom of the stomach,
two and a half inches to the left. The stomach clamps are placed with
handles to the right, their tips holding the lowest point of the stomach,
including a bit of the greater curvature itself. The jejunum is clamped
from one and a half to three and a half inches from its origin, the distal
portion of the clamped folds being placed in the tips of the clamps. In this
technic the jejunum is not reversed, thus avoiding the kink which is formed
in the jejunum when Moynihan's technic is employed. Mayo states that,
although the peristaltic waves of the stomach and of the jejunum travel in
different directions, this fact has apparently made no difference to his results,
which have been excellent. The technic for the lateral anastomosis is not
changed.

ANTERIOR GASTROENTEROSTOMY.

(WOLELEE.. 1 )

The anterior gastroenterostomy is not at present considered to be the
operation of choice, but it is indicated when the posterior operation is
impossible. To quote Robson 2 : "In cases of extensive adhesions, in-
volvement of the posterior wall of the stomach in the disease, a form of
congenital deformity in the shape of a very short mesocolon, the posterior
gastroenterostomy may be impracticable."

1 Wolfler. Cent, fur Chir., 1881, No. 15; 1883, No. 23.

2 Robson. Loc. cit.

Fig. 169. — Diagram, Anterior Gastroenterostomy.
Jejunojejunostomy between proximal and distal coils.

247

OPERATIONS UPON THE STOMACH. 249

Steps :

(1) Abdomen opened; stomach exposed.

(2) Duodenojejunal flexure identified.

(3) Gastrojejunostomy on anterior wall of stomach.

(4) Jejunojejunostomy between afferent and efferent loops.

The abdomen is opened, the stomach turned up as if for a posterior gastro-
enterostomy, and the beginning of the jejunum identified. The stomach
is then turned back into its natural position, with its anterior wall forward,
and about sixteen inches of the jejunum drawn out in front of the great
omentum and the transverse colon. The anastomosis between the stomach
and the jejunum is done at this point, after Wolfler's method, placing the
stoma at the lowest point on the anterior wall, parallel to the greater curva-
ture. After completing the anastomosis, a stay stitch may be placed at
either angle of the suture (Hadra 1 ) to prevent the coils from dragging down
and creating a kink at the opening. It is felt, by a large number of sur-
geons, that circular vomiting is less likely to occur if a jejunojejunostomy is
added between the proximal and the distal coils. The place for this second
anastomosis is about four or five inches below the gastroenterostomy. It can
be done by plain suture, or by mechanical devices, as desired (Fig. 169).

PYLORECTOMY.

This operation consists in the excision of the pyloric portion of the
stomach. The size of the area removed depends, partly, upon the extent
of involvement of the stomach; but the conception of the modern technic
is based almost wholly upon the direction of the lymphatic currents in the
gastric walls, and upon the sequence of infection of the adjoining lym-
phatic glands. The operation derives its importance from the fact that from
60 to 70 per cent, of all gastric cancers originate at or near the pylorus.
Before describing the operation in detail, a short review of the blood and
the lymph supply of the stomach will be given.

The Blood Supply of the Stomach 2 is derived from the celiac axis,
which is made up of three trunks : the gastric, the hepatic, and the splenic
arteries.

1 Hadra. Loc. cit.
* Gray's Anatomy.

250 INTESTINAL AND GASTRIC OPERATIONS.

The Gastric Artery is directed upward to the left, where it joins the
stomach near the cardiac orifice, distributing branches to the esophagus,
which anastomose with the aortic esophageal arteries. Other branches
supply the cardiac end of the stomach, inosculating with branches of the
splenic artery. The gastric artery then passes down on the lesser curvature,
from left to right, to the pylorus, lying, in its course, between the layers
of the lesser omentum, and giving branches to both surfaces of the organ.
At its termination the gastric anastomoses with the pyloric branch of the
hepatic.

The Hepatic Artery supplies the stomach with two vessels : the pyloric,
and the gastroduodenalis.

The Pyloric Artery arises from the hepatic, above the pylorus. It
passes down to the pyloric end of the stomach, and travels from right to
left along the lesser curvature, supplying it with branches, and inosculating
with the gastric artery.

The Gastroduodenalis Artery is a short but large branch which
descends behind the first portion of the duodenum to the lower border of the
stomach where it gives off a large branch, the gastroepiploica dextra, to the
greater curvature.

The Gastroepiploica Dextra Artery passes from right to left along the
greater curvature of the stomach between the layers of the great omentum,
anastomosing about the middle of the lower border of the stomach with
the gastroepiploica sinistra of the splenic artery. It gives off numerous
branches, some of which ascend to supply both surfaces of the stomach,
while others descend to supply the great omentum.

The Splenic Artery contributes two sets of vessels to the blood supply
of the stomach: the vasa brevia, and the gastroepiploica sinistra.

The Vasa Brevia consist of from five to seven small branches which
arise either from the termination of the splenic artery or from its terminal
branches. They pass from left to right between the layers of the gastro-
splenic omentum and are distributed to the greater curvature of the stomach,
anastomosing with branches of the gastric and gastroepiploica sinistra
arteries.

The Gastroepiploica Sinistra Artery, the largest branch of the splenic,
runs from left to right along the greater curvature of the stomach, between

S3"

era

r ^

cr-

tli

S-

a
c

o
c
era

o 9

> \\ N - S

\ V\ \ ■

I '.: '.

Fig. 171. — The Lymphatic Drainage of the Stomach, to Illustrate Cuneo's Division into

Territories.

Glandular groups have the same colors as the areas drained by them.

Pink: Coronary area, coronary group of glands on the lesser curvature.

Yellow: Lower portion of pyloric zone, subpyloric group of glands, about gastroepiploica dextra artery.

Blue: Fundus, splenic chain of glands.

Yellow-shaded: retropyloric group of glands. The coloring stops at the pyloric sphincter to show the

position of the retropyloric group, which are drawn in at the correct level.

2 53

OPERATIONS UPON THE STOMACH. 255

the layers of the great omentum, and anastomoses with the gastroepiploica
dextra. In its course it distributes several branches to the stomach which
ascend upon both surfaces; others descend to supply the great omentum
(Fig. 170).

The Lymph Supply of the Stomach. — The lymphatic drainage of
the stomach has teen thoroughly studied by Cuneo, 1 and the author is
indebted to this investigator for the facts given below (Fig. 171).

The gastric walls are supplied with two sets of lymphatics, the one
draining the mucous layer, the other the muscular layer. The two sets of
lymphatics supplying a given area empty into the same glandular chain.
The general direction of the lymphatic stream is toward the right, except
at the fundus, where it travels toward the left. Each lymphatic stream
empties into a definitely placed group of glands ("first relay"), after which
all currents converge and join at the preaortic glandular group, placed
about the celiac axis ("second relay"). Conversely, each glandular group
drains a definite portion of the stomach walls, and, for this reason, Cuneo
has named these lymphatic territories after the glandular chains with which
they are connected. The main glandular chains are situated, respectively,
about the coronary artery and its branches, the hepatic artery and its
branches, and the splenic artery and its branches.

The coronary or gastric chain of glands receives the lymph from the
two-thirds of the stomach adjoining the lesser curvature. It is comprised
of from two to six glands which are placed along the course of the gastric
artery and its principal branches. In the region of the cardia, a small
mass of glands is found on the ascending branch of the coronary artery
which is in communication with the esophageal lymphatics. In the region
of the pylorus, the coronary stream takes the lymph from the upper half
of the stomach to the glands on the lesser curvature, while the lower half
drains into the glands on the right gastroepiploic artery.

The splenic chain of glands is distributed along the course of the
splenic artery to its termination in the hilum of the spleen. It is comprised
of from four to ten glands which receive the lymph from the area supplied
by the vasa brevia, and the gastroepiploica sinistra (fundus).

The hepatic chain of glands receives its main supply from the liver.

1 Poirier, Delamere, and Cuneo. "The Lymphatics," 1903.
31

256 INTESTINAL AND GASTRIC OPERATIONS.

It also receives the lymph which travels along the secondary chain about
the right gastroepiploic artery. The right gastroepiploic chain is com-
prised of two distinct glandular groups, the subpyloric, and the retropyloric.

The subpyloric chain averages from three to six glands, which are
situated between the layers of the great omentum, beneath the pyloric zone
of the stomach. These glands are but rarely found in the middle part of
the greater curvature, and very rarely in the region of the fundus. This
group is usually placed at a distance from the greater curvature, along
the descending branches of the gastroepiploic arch, and may be left in situ,
during pylorectomy, unless their increase in size renders them apparent.
The subpyloric glands receive the lymph from the inferior part of the
pyloric portion of the stomach and from the upper part of the greater
omentum. Their efferent vessels usually terminate in the retropyloric
group ; but frequently go to the glands about the superior mesenteric vessels.'

The retropyloric chain is placed along the gastroduodenal artery, in
continuity with the subpyloric below and the main hepatic chains above.
It is comprised of two or three glands which are in relation with the pylorus
in front, and with the pancreas behind. This group is not uncommonly
absent, and, when present, was found by Cuneo to have been always in-
fected. They receive the lymph from the subpyloric group, and also from
the posterior surface of the pylorus, and from the first part of the duodenum.
Sappey 1 has demonstrated that there is a communication between the
lymphatics of the stomach and those of the duodenum, although neither
Most 2 nor Cuneo 3 have been able to corroborate his work. There is little
doubt that there is a connection between the duodenum and the stomach, as
the duodenal glands have been injected through the mucosa of the stomach;
but the connecting lymphatics do not show a high grade of development.
The three cardinal facts upon which the technic of pylorectomy is founded
are the following :

1. The slight lymphatic communication between the duodenum and
the stomach impedes the advance of the infection into the intestine.

1 Sappey. Traits d'Anat. Physiologique et Pathologique des vaisseaux lymphatiques, 1874,
p. 76, and following, pi. xxv, Fig. 1.

2 Most. Arch. f. Klin. Chir., lix, i, p. 175.

3 Cuneo. These, Paris, 1900, and CunSo et Delamere, Journal de l'Anat. et de la Physi-
ologie, 1900.

OPERATIONS UPON THE STOMACH. 257

2. Metastases from pyloric cancer first invade the glands on the lesser
curvature, and on the subpyloric part of the greater curvature.

3. The dome of the stomach is practically isolated from lymphatic
infection by pyloric cancer.

It will be noted, therefore, in performing the operation, that, —

1. The duodenum is spared up to within three centimeters of the pylorus.

2. The whole lesser curvature, with its glands, is removed up to within
two and one-half centimeters of the cardia, together with the subpyloric
part of the gastrocolic omentum.

3. The dome of the stomach and a good share of the greater curvature
are saved, following the Hartmann-Mikulicz line of section.

In a recent article W. J. Mayo 1 has collected and simplified the technical
improvements described by Czerny, Kocher, Hartmann, Mikulicz, and
others. The result is a composite operation of great value. In the follow-
ing description the author has followed rather closely the procedure advised
by Mayo:

Steps :

(1) Exploratory abdominal incision.

(2) Gastric artery divided between two ligatures.

(3) Lesser omentum double tied and resected close up to liver.

(4) Pyloric artery divided between two ligatures, and upper end

of duodenum freed.

(5) Ligation of gastroduodenal, or of right gastroepiploic artery.

(6) Gastrocolic omentum resected in sections close to transverse

colon, from right to left, as far as is necessary.

(7) Ligation of left gastroepiploic artery.

(8) Duodenum double clamped and resected, open end closed.

(9) Stomach double clamped and resected, proximal to growth,

open end closed.
(10) Gastrojejunostomy.
The abdomen is entered through a short median incision, half way between
the ensiform cartilage and the umbilicus. Through this opening a careful
digital exploration is made to determine the operability of the growth.
If the condition is found to be inoperable, Mayo closes the abdominal

1 Mayo, W. J. Annals of Surgery, March, 1904.

258 INTESTINAL AND GASTRIC OPERATIONS.

Fig. 172. — Relations around the Head of the Pancreas.
Note the close relation of the gastroduodenal artery to the head of the pancreas.

incision with insoluble mattress sutures of silk, linen, or wire, placed in
the aponeurosis of the linea alba. Sutures of this description will allow
the patient to get about in a few days, and thus avoid the general debility,
and hypostatic pulmonary lesions, which rapidly supervene when advanced
malignant cases remain in bed for the length of time necessary for the
wound to heal completely. If the condition is operable, the incision is
enlarged to four or five inches, and the stomach exposed.

As seen in Fig. 170, the pyloric portion of the stomach is supplied
by four arteries : the gastric and the pyloric on the lesser, and the right and
the left gastroepiploics on the greater curvatures. If these four vessels are
tied at once, the remainder of the operation will be practically bloodless.
The gastric artery is tied double and cut at the point where it reaches the
lesser curvature, about two and one-half centimeters below the cardiac
orifice. The lesser omentum is next tied double and cut in sections, close
up to the liver, from left to right, from the point where the gastric artery has
been tied up to the three large structures placed at the right border of the
omentum (i. e., hepatic artery, common duct, and portal vein). In early cases
of cancer a free excision of the lesser omentum is carried out in the same
manner, since the omental fat may be already infected, before glandular
enlargement is discernible. The pyloric artery is then double tied and
divided near the pylorus, and the first part of the duodenum freed 'or three
or four centimeters, to facilitate its resection later. Fig. 172 shows the rela-
tion of the vessels around the head of the pancreas. The ligature of the gas-
trohepatic omentum mobilizes the pyloric end of the stomach with the tumor
(Fig. 173), so that, by introducing the fingers behind the pylorus, the gastro-
duodenal, or the right gastroepiploic arteries can easily be reached. It
will be remembered that the retropyloric glands lie in the groove between
the duodenum and the head of the pancreas, and receive the lymph from
the subpyloric group in the gastrocolic omentum. These retropyloric
glands must always be removed, if found enlarged; but, as they surround
the gastroduodenal artery, this vessel must be tied above the glands before
trying to dissect them out (Kocher). If these glands are not enlarged, the

Fig. 173. — Pylorectomy.
Gastric and pyloric arteries tied and cut. Section of the lesser omentum, saving the bile duct and
blood-vessels at the edge of the omentum. Clamps on duodenum at the level of future section. The
Hartmann-Mikulicz line of section. (This series is redrawn from W. J. Mayo's technic.)

259

Fig. 174. — Pylorectomy.
Section of duodenum between clamps, distal end partly closed in. Ligature of gastroduodenalis
and of gastroepiploica sinistra arteries. Section of gastrocolic omentum close to transverse colon.
Kocher's clamps on stomach at the Hartmann-Mikulicz line of section.

j6 1

OPERATIONS UPON THE STOMACH. 263

fingers behind the pylorus separate the gastrocolic omentum from the
transverse mesocolon, and the ligature placed farther down on the right
gastroepiploic artery. The gastrocolic omentum is next resected in sections
from right to left for the desired distance on the greater curvature (Fig.
174). The subpyloric glands are situated at a distance from the greater
curvature, and, to be certain of removing all of the infected tissue, the
resection of the gastrocolic omentum must be carried close to the transverse
colon. Metastases from disease of the greater curvature are occasionally
carried to the glands of the transverse mesocolon. This region should be
examined. Sometimes the distal cut edge of the greater omentum becomes
much congested from venous obstruction on the right where it extends out
over the duodenum. In cases where drainage is employed, Mayo advises
excising this devitalized omentum. Care should be exerted, in tying off
the gastrocolic omentum, to separate it from the mesocolon in order to
avoid including in the ligature the colica media artery. This vessel
furnishes practically the whole blood supply to the transverse colon, and
its accidental inclusion in a ligature would not be difficult (Lauenstein, 1
Gutsch, 2 Czerny, 3 Kuster), 4 owing to the normally close apposition of the
mesocolon to the gastrocolic omentum. The left gastroepiploic artery is,
finally, tied at a point on the greater curvature selected for the lower ex-
tremity of the line of section. Figs. 175 and 176 show the relation of the
colica media artery to the gastrocolic omentum. The stomach now being
freely movable, and its posterior wall easily accessible, the peritoneal
cavity is walled off with gauze and the resection begun. In excising the
diseased pyloric portion a difference of opinion exists as to which end should
be first cut away, the distal (duodenal), or the proximal (nearest cardia),
Kocher 5 preferring the former, and Hartmann 6 the latter. Mayo 7 has found
both methods indicated in special cases ; but, as a routine, resects the duo-
denal end first, as it allows a better exposure of the stomach while working

1 Lauenstein. Cent, ftir Chir., 1882, No. 7; ibid., 1885, No. 8, i3i.

2 Gutsch. Bericht iiber den 12 Chirurgen Congress.

3 Czerny. Wien. Med. Woch., 1884, No. 17, p. 18-19.

4 Kuster. Cent, fur Chir., 1884, p. 754.

5 Kocher. Text-Book of Surgery.

6 Hartmann. "Chirurgie de l'estomac," Verhandl. des xni, Internationalen Med. Con-
gresses, Paris, 1900.

7 Mayo. Loc. cit.

264 INTESTINAL AND GASTRIC OPERATIONS.

Fig. 175. — Sound Introduced through the Foramen of Winslow.
Gastrocolic omentum opened to show its close relation to the transverse colon. (Sobotta.)

Fig. 176. — Gastrocolic Omentum Cut and Stomach Lifted, Exposing the Lesser Peritoneal

Cavity.
This demonstrates the danger of including the colica media artery when ligating the gastrocolic omentum

during a pylorectomy.

deep under the costal arch. This method is described later. The integrity
of the duodenum in cancer of the pylorus has been regarded as established,
because of the poor lymphatic communication through the pyloric sphincter.
Cuneo 1 found malignant extension into the intestine in 37 per cent, of the
cases which he examined, and Borrmann 2 in 32 per cent. In these cases
the duodenum frequently appeared, macroscopically, to be intact, when
it had been already invaded. Cuneo considers that the first two
centimeters of the duodenum should be regarded as a suspicious zone,
and that resection should be made at least three to four centimeters
from the sphincter. Two small clamps are applied to the duodenum at a safe
margin from the extreme edge of the growth (Furguson 3 ), and the intestine
divided between them, either with a cautery (Mayo) or with a knife. The
cautery is used to prevent the accidental inoculation of the cut edges with
cancer and to stop hemorrhage at once. The closure of the duodenal stump
is done by sewing the cut edges together with a glover's stitch. The
edges are then invaginated and held in place by a purse-string suture exactly
as described earlier, and shown in Figs, in, 112 and 113.

In determining the proximal line of section, the method of lateral pro-
gression of the growth must be borne in mind. Czerny 4 originally advocated
allowing a margin of only one centimeter from the apparent edge of the
growth. Eiselsberg 3 and Mikulicz find it necessary to remove "several
centimeters, " without stating explicitly how many. Cuneo 7 has shown that
the appearance of the serous surface of the stomach may give no clue to

1 Cuneo. These de Paris, 1900, G. Steinthal; Revue de Chirurgie, 1900, p. 1513.

2 Borrmann. Mitth. aus den Grenzgeb., I. Supplbd., 1901; "Das Wachsthum und die Vor-
breitungwege der Magenscarcinoms," Iena, C. Fischer, 1901.

3 Quoted by Mayo. Jour. Amer. Med. Asso., April 7, 1906.

4 Czerny. Quoted by Guinard in his thesis at Paris: "La cure chirurgicale du cancer de
l'estomac," 1898, p. 125.

5 Eiselsberg. Ibid.

e Mikulicz. Arch. f. Klin. Chir., Bd. lvh, 1898, p. 527.

7 Cundo. These, p. 41, and Soc. Anat. communic. de Tuillet, 1900 (en collaboration avecLecene) ■

flaccid portion of lesser omentum dense portion

left triangular
Itg. of liver

round ligament
of liver

gall-bladder

US***

hepatoduo-
denal lig.

superior portion \A
of duodenum

pylorus

great

(anterior

stomach

omentum

layer)

{transverse colon) posterior layer

of great omentum

diaphragm

m anterior border
Hi of spleen

phrenicocollc
ligament

Fig. 175

right kidney A\

,_ g. ant. layer

t YpT'-ir^ of great
j ■ U' omentum X

inf. extremity
of spleen

Fig. 176

OPERATIONS UPON THE STOMACH.

265

the surgeon whether or not the underlying stomach wall is sound, because
growth spreads most rapidly through the submucous layer (Fig. 177).
The serous layer is not involved until the muscular has been penetrated,
where resistance to the advance of the growth is well known. Czerny
has since proposed leaving a margin of three centimeters from the apparent
edge of the growth, and this has been adopted by Carle and Fantino 1 and
by Hartmann. 2 Cuneo feels that this represents the minimum edge that
should be left, and urges taking more leeway, as a rule.

To recapitulate: The lesser curvature receives the bulk of the lymph-
atic supply from both walls of the stomach. In early cases the omental fat
may be infected when few or no glands
may be found enlarged. For this
reason the whole lesser curvature and
the lesser omentum are to be removed
in every case. Mikulicz's point of elec-
tion is two and one-half centimeters
below the cardiac orifice, just where the
gastric artery is tied. Since the direc-
tion of the lymphatic stream is toward
the right, on the greater curvature,
following the right gastroepiploic ar-
tery, malignant extension to the left will
be less rapid here in proportion to that
on the lesser curvature. On this

account it will be found that a good portion of the greater curvature can be
saved, and, if a point on this curvature at least three centimeters from the
growth be chosen, Hartmann's point of election will be established. By con-
necting the points chosen on the two curvatures, a line of section results
which passes across the stomach obliquely downward and to the right.
Every point of this line must be at least three centimeters from the extreme
apparent edge of the growth.

A long Kocher clamp is placed obliquely across the stomach,
between the two points mentioned above, while a second rubber-

1 Carle and Fantino. Arch. f. Klin. Chir., Bd. lvi, 1898, H. 1 and 2, p. 226.

2 Hartmann. "Chirurgie Gastro-intestinale," Paris, 1901.

Fig. 177. — Pylorectomy.
Shows manner of extension of growth
(from Hartmann and Cuneo). jl. Mucosa;
2, submucosa; 3, muscularis; 4, serosa; 5,
floor of malignant ulcer; 6, edge of ulcer;
7, lateral limit of extension of growth in mu-
cosa; 8, lateral limit of extension of growth
in submucosa; 9, metastatic nodules in sub-
mucosa; 10, safe margin for resection of
stomach wall.

266

INTESTINAL AND GASTRIC OPERATIONS.

covered clamp is applied about one inch proximal to the first clamp
and parallel with it. The resection is made between the two clamps along
the Hartmann-Mikulicz line, either with a cautery, or with scissors, leaving
an edge of at least half an inch projecting through the proximal clamp.
When scissors are employed for resecting the stomach the two walls should
be cut away separately, directly through all coats, the mucous membrane
being trimmed down later flush with the muscular coats. It is possible
to cut the muscular and the mucous coats at the same time in such

Fig. 17S. — Pylorectouy.
The lower figure shows the method of holding the scissors. The upper figure shows the line in
which the scissors cut, when held in the position shown in the corresponding figure below. 1' and 2'
show the resulting cut edges, after holding the scissors as in 1 and 2. When held straight as in 1, the
mucous membrane projects beyond the muscle coats; when held on the oblique as in .', the mucous
membrane is trimmed flush.

a way that it will leave the two coats flush, without further trimming.
This is done by pressing the inside blade of the scissors close to the mucous
membrane on the clamp side, and thus bevelling the mucous membrane
as the scissors cut (Fig. 178). After the resection is completed, the cut
edges tend to retract through the proximal clamp at the two extremities of
the wound. A snap placed on either end will prevent this while the first
layer of sutures is being introduced. The cut edges are sewed together in
the usual manner, with two layers of stitches, an inner througlvand-thoush

Fig. 179. — Pylorectomy.
The distal end of the duodenum is now wholly closed in. Note tied gastric, pyloric, gastroduo-
denalis, and gastroepiploica sinistra arteries. Stomach practically closed in. Posterior gastroen
terostomy.

267

OPERATIONS UPON THE STOMACH. 269

and an outer seromuscular. Both sutures may be continuous. After the
introduction of the inner layer the clamp is taken off and any bleeding
points tied at once (Fig. 179). Before carrying the seromuscular stitch
across the stump, it will be found of advantage to close in the two projecting
ends. For this purpose two interrupted stitches, such as the author's
mattress, are used.

The last step in the operation consists in again connecting the intestinal
tract with the stomach. Three methods are in use to accomplish this
anastomosis: 1. By joining the distal open end of the resected duodenum
to the open end of the stomach, after reducing the caliber of the gastric
opening to that of the intestine (Billroth 1 ). This technic is being generally
abandoned because of the great danger of leakage, although it is still giving
good results to Conant 2 , and others. 2. By anastomosing the cut duodenal
end to the stomach at a sound spot on its posterior wall, after wholly closing
the open end of the stomach (Kocher 3 ). 3. The technic which gives
the best results, and which was also suggested by Billroth, namely, a gastro-
jejunostomy, preferably on the posterior wall, after closing the open-ends,
both of the stomach and the duodenum. 4

Drainage is not usually necessary, but when sepsis is feared a cigarette-
wick should be placed at the lower angle of the wound, reaching down to
a point just above the transverse colon (Mayo 5 ).

PARTIAL GASTRECTOMY.

This operation (resection of the middle portion of the stomach) is done
for disease of the body of the stomach, such as stricture, or for malignant
disease. The technic is merely an application of the usual methods for
lateral anastomosis.

Steps :

(1) Ligature of vesels on the greater and the lesser curvatures.

(2) Double ligature of omenta in section; resection between

ligatures.

1 Billroth. I. Wien. Med. Wochenschr., 1881, No. 6, S. 162.

2 Conant. Unpublished technic.

3 Kocher. Archiv fur Klin. Chir., 1891, Bd. xlh, S. 542.

4 Billroth. II. Reported by von Hacker, Die Verhandl. der Deutsch. Gesellsch. fur Chir.,
1885, Part n, Vol. xiv, p. 62.

5 Mayo. Loc. cit.

270 INTESTINAL AND GASTRIC OPERATIONS.

(3) Clamps.

(4) Resection of the stomach.

(5) End-to-end anastomosis.

The stomach is withdrawn from the abdomen, and the causes of the con-
dition investigated. The transverse mesocolon should be specially
examined since its glands receive lymph from the stomach. This operation
is usually performed for malignant disease, and a discovery of glands
in one of the pathognomonic situations will give a clue to the extent
and the site of the lesion. The ligature of the vessels on the curvatures
is simpler than is the case in the pylorectomy, because the arteries
are all tied at more easily accessible points. On the lesser curvature
the descending branch of the gastric artery is tied double and cut on
each side of the area to be resected, but leaving enough of the vessel to be
sure of a good supply for the sutured edges. On the greater curvature,
the epiploic arteries are tied in the same manner as was the gastric, on each
side of the area to be cut out. If a suspicion of malignancy exists, a good- -
sized V must be excised, both from the greater and from the lesser omenta.
The V of greater omentum must include the subpyloric glands close to the
transverse colon, while in the lesser omentum all glands and doubtful
tissue are taken out. This operation, in other words, must conform with
Hartmann and Cuneo's rules for pylorectomy (Fig. 180). After the
omenta have been ligated, in sections, walling-off gauze is slipped beneath
the stomach to protect the lesser peritoneal cavity from infection. The
stomach is now double-clamped on either side of the area to be removed.
The clamps are placed about one inch apart, allowing from one and one-
half to two inches margin of healthy tissue. Harrington's straight clamps
were designed for this operation. The resection is best done with
scissors, in the method adopted for the pylorectomy, wiping away the
mucus and contents which leak out as the incision is made. After
the diseased portion of the stomach has been taken away and the
edges of the gastric walls, projecting through the clamps, wiped clean, a
fresh slip of gauze is substituted, to wall off the lesser peritoneal cavity,
and the two clamps are brought side by side. There are several methods
of anastomosing the stomach end to end. Scudder 1 has successfully applied

1 Scudder. Annals of Surgery, 1905, Vol. 41, p. 712.

Fig. 180. — Resection of the Middle Portion of the Stomach.

Harrington's straight clamps in position. Incisions have been made into both mesenteries. Section

lines on stomach indicated by dotted lines.

271

Fig. 181. — Resection of the Middle Portion or the Stomach.
End-to-end anastomosis of stomach after resection. Clamps turned to present cut edges. First
half of seromuscular stitch placed. Through-and-through stitch begun; overlapping portion on greater
curvature closed in.

273

OPERATIONS UPON THE STOMACH.

275

the Connell interrupted mattress suture to this situation, while Moynihan
and others sew the cut edges together in two layers. As the second method
is the one more generally used, this technic is described below.

The anastomosis consists of outer continuous seromuscular and inner
continuous through-and- through stitches. Upon bringing the two clamps
side by side, it will be found that the upper portion of the stomach has a
larger caliber than that of the lower. The two openings are brought to

Fig. 182. — Resection of the Middle Portion of Stomach.
Suture completed. Omenta approximated. Overlapping portion on greater curvature turned in with

mattress sutures.

the same caliber by taking a reef in the larger, and the anastomosis per-
formed as follows: The clamps are held together, in such a manner
that the line of the lesser curvature is restored, leaving the redundant edge
of the upper portion to overlap on the greater curvature. The handles
are now given a quarter turn, so that the cut edges project forward, thus
facilitating the introduction of the first half of the seromuscular stitch,
which is placed in the space intervening between the cut edges and the
clamps (Fig. 181). The redundant edges of the upper portion are sewed

276 INTESTINAL AND GASTRIC OPERATIONS.

together with a continuous stitch, and the remainder of the anastomosis
done in the usual manner. The slip of walling-off gauze is afterwards re-
moved, and the omental incisions closed with interrupted sutures (Fig. 182).
When a very large section of the middle portion of the stomach has been
removed it will be found preferable to join the distal segment to the greater
curvature of the proximal segment, in a way similar to Billroth's first
technic for pylorectomy. 1 In this manner the best drainage is obtained.
After resections which leave the openings of the upper and the lower seg-
ments at approximately the same caliber it is simpler to restore the lesser
curvature, as described earlier, and turn in the edges of the upper segment
which overlap at the greater curvature.

EXCISION OF ULCER.

The suspicion that an ulcer is underlying malignant degeneration
warrants the excision of the doubtful area. When the ulcer is accessible,
the technic is obvious. Excision of an ulcer on the lesser curvature requires
more elaborate technic. Vallas 2 has described a case of this type, and his
method is adopted below:

Steps :

(1) Clamps.

(2) Excision of V of lesser curvature.

(3) Anastomosis, line of lesser curvature restored.

The gastric artery is tied double, and cut, on each side of the diseased area,
as has been described before. The lesser omentum is ligated in sections
to include the glandular masses adjoining the gastric lesion, and the clamps
applied. These are placed about one inch outside of the extreme limit of
induration to take in a V-shaped section of the lesser curvature. This V
includes a portion of both stomach walls, with its base above and its apex
below. If the tips of the two clamps touch at the apex of the triangle leakage
from the stomach will be prevented. The excision is now done with scissors,
leaving an ample free edge projecting from both instruments (Fig. 183).
Vallas found great difficulty in applying two layers of sutures to the pos-
terior edges of the opening; the Connell mattress method is more applic-

1 Clark. Journal Am. Med. Asso., Chicago, 1905, xliv, 1613.

2 Vallas. Lyon Mddical, 1905, civ, 404-407.

Fig. 183. — Resection of an Ulcer on the Lesser Curvature.
Clamps. Vessels tied. Excision of triangular portion of the stomach, on lesser curvature. Excision of

glands in the lesser omentum.

277

...( ym

Fig. 184. — Eesection oe an Ulcer on the Lesser Curvature.
Posterior edges of wound approximated with Connell mattress sutures. Anterior edges approximated

with two layers of continuous stitches.

279

OPERATIONS UPON THE STOMACH.

201

able. These stitches can be put in, from apex to base, until the lesser
curvature is reached, after which the front can be closed in with two layers
of continuous stitches, as usual (Fig. 184).

GASTROPLASTY.

The operation described below consists in the application of the Heinecke-
Mikulicz principle of pyloroplasty to a stricture in the body of the stomach.

Fig. 185. — Gastroplasty for Hour-glass Stomach.
Clamp^first applied parallel to long axis of stomach. Stomach opened; mucous membrane trimmed

flush with muscle.

The purpose of the operation is to increase the caliber of the stomach at
the site of the constriction. Its use is advocated by Bardeleben, 1 Krucken-
berg, 2 Eiselsberg, 3 and others.

1 Bardeleben. Klemperer, Berliner Klin. Woch., 1889.

2 Kruckenberg. Schmidt-Monard, Munch. Med. Woch., 1893, No. 19.

3 Eiselsberg. Archiv fiir Klin. Chir., 1899.

252 INTESTINAL AND GASTRIC OPERATIONS.

Steps :

(i) Clamp applied in long axis of stomach.

(2) Incision into fold included by clamp, with excision of redun-

dant mucous membrane.

(3) Clamp removed, incision pulled out until at a right angle to

its original position, and clamp reapplied.

(4) Wound sewed together with two layers of sutures.

The object of the clamp is, of course, to control hemorrhage and to pre-
vent leakage of the gastric contents. It grasps a fold in the long axis of
the stomach, after which an incision is made through the fold held by the
clamp, and the redundant mucous membrane excised (Fig. 185). The
middle points on the lips of the wound are then seized with forceps and the
clamp loosened. The two middle points, grasped by the forceps, are now
separated from each other by pulling upward with one hand and downward
with the other hand, at the same time lifting forward. This prevents leakage
while the other clamp is off, and leaves the incision at a right angle to its
original direction. The clamp is next tightly reapplied, thus holding the
cut edges in their new position (Fig. 186). The points which correspond
to the angles of the original incision are now in the middle of the clamp
blades. These points will tend to retract, and should be pulled well through
the blades and held fast, if necessary, with small hemostatic forceps. The
incision is sewed together with two layers of sutures, an inner through-and-
through, and an outer seromuscular, both of which are continuous. The
clamp is removed before placing the outer suture, for the usual reasons.

GASTROGASTROSTOMY.

In 1894 Wolfler 1 first performed intergastric anastomosis between the two
pouches of an hour-glass stomach, since when it has been frequently done in
suitable cases. The operation is essentially a lateral anastomosis.

Steps :

(1) Clamps.

(2) Lateral anastomosis.

The clamps are placed across the stomach, taking up long folds. The lower

1 Wolfler. Beitrage zur Klin. Chir., 1895, No. 13.

Fig. 186. — Gastroplasty.
Line of incision drawn out until at right angles to original position; clamp reapplied to hold edges in

new position without hemorrhage.

=33

Fig. 187. — Gastrogastrostomy for Hour-glass Stomach.
Clamps in position for lateral anastomosis; folds open; dotted line shows Kammerer's method of con-
necting two incisions and applying Finney's technic.

2S5

Fig. 188. — Gastroplication.
Method of placing the stitches in the anterior wall.

2S7

,\C ? - ■%

LIBRARY

^0 ^ c

Fig. 189. — Gastroplication.
Anterior wall plaited by tying the stitches.

Fig. 190. — Gastroplication.
Cross section showing plaits in the anterior wall. Posterior gastroenterostomy.

291

OPERATIONS UPON THE STOMACH. 293

angles of the folds include portions of the greater curvature and omental
attachment, for the incisions necessarily are made low to obliterate the
pouches (Fig. 187). The usual technic for lateral anastomosis is adopted.
Kammerer 1 has successfully applied Finney's gastroduodenostomy technic
to gastrogastrostomy. The dotted line in Fig. 187, connecting the upper
angles of the clamped folds, shows Kammerer's method of converting a
simple gastrogastrostomy into Finney's operation. For directions as to
the application of the clamps for Kammerer's operation the reader is
referred to the technic of gastroduodenostomy, page 229.

GASTROPLICATION.

Folding of the stomach, to diminish its size, is said to be indicated in
those rare cases of atonic dilatation of the stomach not caused by obstruction
of the pylorus. The operation was originated by Bircher, 2 in 1890. It
has been performed since then, with a certain amount of success, by Weir, 3
Bennett, 4 Brandt, 5 Moynihan, 6 C. B. Porter, 7 and others. Moynihan's
technic is given here:

(1) A series of interrupted seromuscular stitches are placed across

the anterior wall of the stomach.

(2) The tying of these stitches folds in the stomach.

(3) Posterior gastroenterostomy.

Moynihan has modified Bircher's and Weir's technic. He introduces a
number of interrupted stitches which start from the lesser curvature and
travel across the body of the stomach, parallel with each other (Fig. 188).
Each stitch comprises a series of bites taken in the anterior wall of the
stomach, about one inch apart. Upon drawing tight the threads, the
stomach wall is folded into as many creases as there are bites in each stitch.
Great care must be taken not to cause obstruction by placing the stitches
too close to either aperture of the stomach (Fig. 189). Moynihan does

1 Kammerer. Annals of Surgery, 1903, Vol. xxxvn, p. 281.

2 Bircher. Correspondenzbl. fur Schweiz., Aertze, 1891, p. 713.

3 Weir. New York Medical Journal, 1892, July 9, p. 29.

4 Bennett. London Lancet, July 4, 1896, p. 8.

5 Brandt. Cent, fur Chir., 1894, p. 36.

6 Moynihan. London Lancet, April, 30, 1898, p. 1177.

7 Porter, C. B. Trans. American. Surgical Asso., 1897.

294 INTESTINAL AND GASTRIC OPERATIONS.

not attempt to plait the posterior wall, since this difficult move has not
given the best results. He was once obliged to add a posterior gastro-
enterostomy on a return of the symptoms, a measure which proved wholly
successful. It would seem advantageous to perform the gastroenterostomy
at once, in view of the fact that a deep pouch is otherwise left in the posterior
wall (Fig. 190).

INDEX OF NAMES.

Abbe, 162, 177, 210
Allingham, 183, 185
Audry, 187

Barbat, 47, 48, 51, 53
Bardeleben, 281
Bardenheuer, 160
Bayliss, 125
Beer, 165
Bennett, 293
Berndt, 202
Billroth, 269
Binnie, 100
Bircher, 293
Blake, 45, 219
Boas, 212
Borrmann, 264
Brandt, 293
Braun, 240
Briau, 136
Burghard, 203

Cannon, 45, 219

Carle, 2r2, 265

Charpy, 109

Cheyne, 203

Clark, 276

Conant, 269

Connell (F. G.), 8o, 91, 95, 145

Connell (M. E.), 91, 164, 165

Cuneo, in, 255, 256, 264

Cushing, 21, 80, 81

Czerny, 257, 263, 264

Delamere, in, 255
Diffenbach, 83
Doyen, 86, 100, 160
Dupuytren, 83
D wight, 109

ElSELSBERG, 264, 281

Elliott, 133

Fantino, 212, 265
Fenger, 210
Ferguson, 264
Finney, 225, 231
Fischer, 205
3°

Franck, 205, 210
Fronmuller, 221

Gant, 183, 186, 196

Gaston, 170

Girard, 205

Gould, 45, 85, 99, 177, 225, 242, 266

Gray, 249

Gutsch, 263

Hadra, 244, 249

Hahn, 44, 205, 217

Halsted, 79, 95

Harrington, 20, 104, 128, 151, 220

Hartmann, 257, 263, 265

Heinecke, 221, 281

Heister, 80

Henke, 114

Henle, 222

Hirsch, 212

Horsley, 96, 97

Jaboulay, 136, 165, 222, 240

Jobert, 80, 92

Johns Hopkins Hospital, 44

Kader, 205

Kammerer, 212, 293

Kausch, 43

Kocher, 44, 104, 105, 222, 233, 258, 263, 269

Krause, 100, 103, 234

Kruckenberg, 281

Krister, 263

Latjenstein, 263
Lembert, 79
Lennander, 46
Lindstrom, 212
Littlewood, 237, 241
Loreta, 212

Madelung, 135

Mall, 41, 1 14, 126

Marwedel, 205

Mass. Gen. Hospital, 129

Maunsell, 21, 80, 91, 135

Maydl, 183, 184

May lard, 100

=95

296

INDEX OF NAMES.

Mayo (W. J.), 90, 160, 171, 172, 221, 225, 237,

244, 246, 257
McGraw, 170, 172, 188
McLean, 171

Mikulicz, 43, 221, 257, 263, 265, 281
Mixter, 186, 188
Monks, 109, 114, 131
Most, 256

Moynihan, 100, 129, 132, 221, 237, 238, 293
Munro, 237, 243

Murphy (F. T.), 55. 57. 59. 61, °4, 170
Murphy (J. B.), 47, 88, 92, 99, 128, 150

Nichols, 20
Nothnagel, 125, 126

Ochsner, 171, 173
Oviatt, 77

Pagenstecher, 21
Pean, 100, 101
Piersol, 17

Poirier, 109, in, 255
Porter (C. A.), 144, 234
Porter (C. B.), 70, 293

Quain, 113

Richardson, 75, 222

Robson, 43, 151, 152, 170, 221, 246

Roux, 44

Salicetto, 89

Sappey, 256

Schede, 130

Scudder, 69, 100, 103, 145, 27c

Sernoff, 114

Ssbanajew, 205, 210

Starling, 125

Steinthal, 45

Stohr, 17, 18, 19

Swain, 212

Thayer, 212
Tiegel, 43, 44, 45
Tixier, 222
Treves, 131

Ullmann, 205

Vallas, 276
Villard, 222
Virchow, 44
Von Hacker, 187, 205, 237

Watts, 45
Weinberg, 114
Weir, 186, 293
Welch, 44
Winiwarter, 160
Witzel, 205, 206
Wolfler, 237, 246, 282

INDEX

Allingham's left inguinal colostomy, 183
Anastomosis, end-to-end, 130, 137-143

by Harrington's segmented ring, 153-157

by mattress stitch, 145-150

by mechanical devices, 149

by Murphy button, 150-153

by Robson's decalcified bone bobbin, 153-

158
Connell's method, 145-150
dangers, 133
eight days, 29
fourteen days, ^^
of large intestine, six weeks, 37
plain, 134
three days, 25
end-to-side, 177-182

Gould's method, 177-182
lateral intestinal, 162. See also Intestinal an
astomosis, lateral.
Animals, Mall's experiments with, 41
Anterior colostomy, 186-194
gastroenterostomy, 246-249
Womer's, method, 246
Appendix, vermiform, burying stump of, 85, 8(
collecting trunks of, anatomy, 112
lymphatics of, 1 1 1
Artery, colica media, no
gastric, 250
gastroduodenalis, 250
gastroepiploica dextra, 250

sinistra, 250
hepatic, 250
pyloric, 250
splenic, 250
Ascending colon, lymphatics of, in
Auerbach's plexus, 125

Bile duct, common, lymphatics of, and lym

phatics of duodenum, relations, 114
Blind end of intestine, formation of, 158
by purse-string operation, 160
by suture in two layers, 158
Blood supply of intestines, 106
of large intestine, no
of small intestine, 106
of stomach, 249

Blood-vessels of intestine, 19

examinations of, in localization, 118
Bone bobbin, Robson's, decalcified, end-to-end
anastomosis by, 153-158
lateral intestinal anastomosis by, 170
Button, Jaboulay's, lateral intestinal anastomo-
sis by, 165-169
Murphy, end-to-end anastomosis by, 150-153
repair following use of, 47
forty-two days, 53
sixty-three days, 53
thirty-six days, 51
three days, 51
Buttonhole suture, 90
doubled, 90

Carcinoma of intestine, 129

Catgut, 65

Cecal collecting trunks, anterior, anatomy of, 112

posteripr, anatomy of, 112
Ceco-appendicular collecting trunks, anatomy of,

in
Cecum, lymphatics of, in
Celloidin linen thread, 66
Circle, vicious, 220
! Circumcision clamp for intestine, 99
Clamp, circumcision, for intestine, 99

Gould's, 100

Harrington's 104

Kocher's crushing, 104

Krause's, 100

Scudder's, 100
Clamps, 98

for extensive resections of stomach, 100

for gastroenterostomy, 100

for stomach operations, 100

gastric, 100

intestinal, 98

Maylard's method of using forceps for, 100
Pean's method of using hemostatic forceps
and rubber tube for, 100
Colica media artery, 1 10

Collecting trunks of appendix, anatomy of, 112
Colon, ascending, lymphatics of, in

descending, lymphatics of, 1 1 1

iliopelvic, lymphatics of, in
297

2 9 8

INDEX.

Colon, transverse, lymphatics of, in
Color of intestine in localization, 117
Colostomy, 182

anterior, 186-194

inguinal, 182
left, 183-186

left inguinal, 183-186

lumbar, 182

permanent, 183

temporary, 183

with glass tube, 196

with McGraw's rubber ligature, 194
Connell's mattress method of lateral intestinal
anastomosis, 164

method of end-to-end anastomosis, 145-150

through-and-through mattress suture, 91
Continuous suture, through-and-through, 89
Contractions, peristaltic, of intestine, in localiza-
tion, 125
Coronary chain of glands, 255
Crushing clamp, Kocher's, 104
Curved needle, method of holding, 67

Moynihan's, Scudder's modification, 69
Cushing right-angle continuous stitch, 81

Decalcified bone bobbin, Robson's, end-to-end

anastomosis by, 153-158
Descending colon, lymphatics of, 111
Distention of intestines, drainage of, 131
Drainage of distended intestines, 131
Duodenum, lymphatics of, 113

and lymphatics of common bile duct, rela-
tions, 114

Elastic ligature, repair following use of, 63
Eud-to-end anastomosis 130, 137-143

by Harrington's segmented ring, 153-157

by mattress stitch, 145-150

by mechanical devices, 149

by Murphy button, 150-153

by Robson's decalcified bone bobbin, 153-
158

Connell's method, 145-150

dangers, 133

eight days, 29

fourteen days, 33

of large intestine, six weeks, 37

plain, 134

three days, 25
End-to-side anastomosis, 177-182

Gould's method, 177-182
Enterectomy, 128
Excision of ulcer of stomach, 276-281

Vallas' method, 276
Experiments, Barbat's, with Murphy button, 47
Beer's, with Jaboulay's button, 47

Experiments, Cannon and Blake's, 219
Harrington and Gould's, 20
Mall's, on repair, 41
Murphy's, with elastic ligature, 63
Senn's, omental grafting, 144

Fat, small masses of, in intestinal localization, 118
Finney's method of gastroduodenostomy, 225

Gould's modification, 225
Food in stomach, movements of, after gastroin-
testinal operations, 219
Formation of blind end of intestine, 158
by purse-string operation, 160
by suture in two layers, 158
Franck-Ssbanajew gastrostomy, 211

Gangrene of intestine, 130
Gant's left inguinal colostomy, 183
Gastrectomy, partial, 269-276
Gastric. See also Stomach.
artery, 250
chain of glands, 255
Gastroduodenalis artery, 250
Gastroduodenostomy, 222-235
Finney's method, 225

clamps for, 225
Kocher's method, 233-235
Gastroenterostomy, 237
anterior, 246-249

Wolfler's method, 246
by plain suture, seventeen months, 39
clamp for, 100

peptic ulcer of jejunum after, 43, 49
etiology, 43
frequency, 43
pathology, 45
posterior, 237-246
Mayo's method, 246
Moynihan's method, 238
Von Hacker's method, 237
twelve days, 31
twenty-one days, 35
Gastroepiploica dextra artery, 250

sinistra artery, 250
Gastrogastrostomy, 282
Wolfler's method, 282
Gastrointestinal operations, movements of food

in stomach after, 219
Gastroplasty, 281

application of principle of Heinecke-Mikulicz
pyloroplasty to, 281
Gastroplication, 293

Moynihan's method, 293
Gastrostomy, 202

Ssbanajew-Franck, 210
Witzel's, 206-210

INDEX.

299

Gastrotomy, 201
Glands, coronary chain of, 255
gastric chain of, 255
hepatic chain of, 255
mesenteric, of small intestine, 113
primary group, 113
second group, 113
third group, 113
retropyloric chain of, 256
splenic chain of, 255
subpyloric chain of, 256
Glass tube, colostomy with, 196
Glover's through-and-through continuous su-
ture, 89
Gould's clamp, 100
mattress stitch, 85
method of end-to-side intestinal anastomosis,

177-182
modification of Finney's gastroduodenostomy,
225
Graft, omental, 144

Hahn's method of stretching pylorus, 217
Halsted mattress stitch, 84

Harrington's ring, lateral intestinal anastomosis
by, 169

segmented ring, end-to-end anastomosis by, 153

stomach clamp, 104
Hartmann-Mikulicz line in pylorectomy, 259
Hartmann's point of election in pylorectomy, 265
Heinecke-Mikulicz pyloroplasty, 221

application of principle, to gastroplasty, 281
Heister's buttonhole suture, 90
Hepatic artery, 250

chain of glands, 255

Iliopelvic colon, lymphatics of, in
Inguinal colostomy, 182

left, 183-186
Intestinal anastomosis, end-to-end, 130. See also
End-to-end anastomosis.
end-to-side, 177-182

Gould's method, 177-182
lateral, 162

by Harrington's ring, 169
by Jaboulay's button, 165-169
by mattress suture, 164
by McGraw's rubber ligature, 170-177
by mechanical devices, 165
by plain suture, 162
by Robson's bone bobbin, 170
five days, 27
clamps, 98
Maylard's method of using forceps for, 100
Pean's method of using forceps and rubber
tube for, 100

Intestinal localization, 114
color of intestine in, 117
determination of direction of loop of intestine

in, 118
examination of blood-vessels of intestine in,

118
length of intestine in, 117
peristaltic contractions of intestine in, 125
size of intestine in, 117
small masses of fat in, 118
thickness and transparency of mesentery in,
118
of intestine in, 117
wounds, repair of, 1 7
Intestine, anatomy of, 106
blind end, formation of, 158

by purse-string operation, 160
by suture in two layers, 158
blood supply of, 106
blood-vessels of, 19

examination of, in localization, 118
carcinoma of, 129
color of, in localization, 117
distention of, drainage in, 131
experimental research on repair of, 20
external coat, 17
formation of blind end, 15S

by purse-string operation, 160
by suture in two layers, 158
gangrene of, 130
internal coat, 19
large, blood supply of, no

lymphatics of, in
length of, in localization, 117
loop of, determination of direction, in intestinal

localization, 118
lymphatics of, 19, m
mucous coat, 19
repair of, 23
muscular coat, 18
repair of, 24
new growths of, 129
operations upon, 128

peristaltic contractions of, in localization, 125
repair of, after introduction of elastic ligature, 63
serous coat, 17

repair of, 24
size of, in localization, 117
small, blood supply of, 106
lymphatics of, 112
mesenteric glands of, 113
primary group, 113
second group, 113
third group, 113
mesentery of, vascular anatomy, 109
stricture of, 129

3oo

INDEX.

Intestine, structure of, 17
submucous coat, 18

repair of, 41
thickness of, in localization, 117
valvular conniventes of, 117

Jaboulay's button, lateral intestinal anastomosis

by, 165-169
Jejunoileum, lymphatics of, 112
Jejunum, peptic ulcer of, after gastroenterostomy,

etiology, 43

frequency, 43

pathology, 45
Jobert-Senn suture, 92

Knot, Richardson's one-hand, 75-77

seamstress, 77-79

square, tying of, 70-75

surgeon's, 79

tying, 70-75
Kocher's crushing clamp, 104

method of gastroduodenostomy, 233-235
Krause's clamp, 100

Lateral intestinal anastomosis, 162. See also

Intestinal anastomosis, lateral.
Leakage of suture, causes, 65
Left inguinal colostomy, 183-186
Lembert stitch, 83

Length of intestine in localization, 117
Ligature, elastic, repair following use of, 63

McGraw's rubber, colostomy with, 194

lateral intestinal anastomosis by, 170-177
McLean's needle for, 171
Line, Hartmann-Mikulicz, in pylorectomy, 259

of section, determining of, in pylorectomy, 264
Localization, intestinal, 114. See also Intestinal

localization.
Loop of intestine, determination of directions, in

localization, 118
Loreta's method of stretching pylorus, 212
Lumbar colostomy, 182
Lymphatics of ascending colon, 1 1 1

of cecum, in

of descending colon, in

of duodenum, 113

and common bile duct, relations, 114

of iliopelvic colon, in

of intestine, 19, 11 1

of jejunoileum, 112

of large intestine, in

of small intestine, 112

of stomach, 19, 255

of transverse colon, in

of vermiform appendix, in

Mall's experiments with animals, 41

Mattress mesenteric suture, 91
suture, 84
Gould, 85
Halsted, 84

end-to-end anastomosis by, 145-150
lateral intestinal anastomosis by, 164
seromuscular penetrating, 92
through-and-through, 91
Maunsell's mattress mesenteric stitch, 91
Maydl's left inguinal colostomy, 183
Maylard's method of using forceps for intestinal

clamps, 100
Mayo's method of pylorectomy, 257

modification of attaching jejunum to posterior
wall of stomach, 246
McGraw's rubber ligature, colostomy with, 194
lateral intestinal anastomosis by, 170-177
McLean's needle for, 171
McLean's needle for McGraw's rubber ligature,

171
Mechanical devices, end-to-end anastomosis by,
149
lateral intestinal anastomosis by, 165
Mesenteric glands of small intestine, 113
primary group, 113
second group, 113
third group, 113
suture, mattress, 91
Mesentery of small intestine, vascular anatomy
of, 109
thickness and transparency of, in intestinal
localization, 118
Mikulicz-Hartmann line in pylorectomy, 259
Mikulicz-Heinecke pyloroplasty, 221

application of principle, to gastroplasty, 281
Mikulicz's point of election in pylorectomy, 265
Milliner's needle No. 3, 69
Mixter's anterior colostomy, 186
Movements of food in stomach after gastroin-
testinal operations, 219
Moynihan's curved needle, Scudder's modifica-
tion, 69
method of gastroplication, 293
Mucous coat of stomach and intestine, 19

repair of, 23
Murphy button, end-to-end anastomosis by, 150—

153
repair following use of, 47
forty -two days, 53
sixty-three days, 53
thirty-six days, 51
three days, 51
purse-string suture, 88
Muscular coat of stomach and intestine, 18

repair of, 24
Muscularis mucosae, 19

INDEX.

301

Needle, curved, method of holding, 67

McLean's, for McGraw's rubber ligature, 171

Milliner's, No. 3, 69

Moynihan's curved, Scudder's modification, 69

Needles, 69

New growths of intestine, 129

Nothnagel's salt test, 125, 126

Omental graft, 144
One-hand knot, Richardson's, 75-77
Operations for non-malignant stricture of pylorus,
218
gastrointestinal, movements of food in stomach

after, 219
stomach, clamps for, 100
upon intestines, 128
upon stomach, 201

Pagenstechee's celloidin linen thread, 66

Partial gastrectomy, 269-276

Pean's method of using hemostatic forceps and

rubber tube in place of clamp, 100
Peptic ulcers of jejunum after gastroenterostomy,

43. 49
etiology, 43
frequency, 43
pathology, 45
Peristaltic contractions of intestine in localization,

125

Permanent colostomy, 183
Plain end-to-end anastomosis, 134
suture, experiments with, 22
table of, 22
gastroenterostomy by, seventeen months, 39
Plexus, Auerbach's, 125
Posterior gastroenterostomy, 237-246

von Hacker's method, 237
Purse-string suture, 86

formation of blind end of intestine by, 160
Murphy, 88
Pylorectomy, 249-269

determining line of section in, 264
Hartmann-Mikulicz line in, 259
Hartmann's point of election in, 265
Mayo's method, 257
Mikulicz's point of election in, 265
Pyloric artery, 250
Pylorodiosis, 211
Hahn's method, 217
Loreta's method, 212
Pyloroplasty, 221

Heinecke-Mikulicz method, 221

application of principle of, to gastro-
plasty, 281
Pylorus, stretching of, 211
Hahn's method, 217

Pylorus, stretching of, Loreta's method, 212
stricture of, non-malignant, operations for, 218

Repair, experiments on, 20

following use of elastic ligature, 63
of Murphy button, 47
forty-two days, 53
sixty-three days, 53
thirty-six days, 51
three days, 51
of intestine after introduction of elastic ligature,

Resections, extensive, of stomach, clamps for, 100
Retropyloric chain of glands, 256
Richardson's one-hand knot, 75-77
Ring, Harrington's, lateral intestinal anastomosis
by, 169
segmented, end-to-end anastomosis by, 153—

157
segmented, experiments with, 20
table of, 21

Robson's bone bobbin, lateral intestinal anasto-
mosis by, 170
decalcified bone bobbin, end-to-end anastomo-
sis by, 153-158
Rubber ligature, McGraw's, colostomy with, 194
lateral intestinal anastomosis by, 170-177
McLean's needle for, 171
tubing for intestinal and small stomach clamps,
99

Salt test, Nothnagel's, 125, 126
Scudder's modification of Moynihan's curved
needle, 69
straight clamp, 100
Seamstress knot, 77-79
Segmented ring, experiments with, 20
table of, 21
Harrington's, end-to-end anastomosis by, 153
Senn-Jobert suture, 92
Seromuscular penetrating mattress suture, 92

stitch, 80
Serous coat of stomach and intestine, 17

repair of, 24
Silk, 66

Size of intestine in localization, 117
Splenic artery, 250

chain of glands, 255
Square knots, tying, 70-75
Ssbanajew-Franck gastrostomy, 210
Stitch. See Suture.
Stomach, blood supply of, 249
blood-vessels of, 19
clamp, Gould's, 100
Harrington's, 104

3° 2

INDEX.

Stomach clamp, Krause's, ioo
Scudder's, ioo
clamps, ioo

experimental research on repair, 20
external coat, 17
food in, movements of, after gastrointestinal

operations, 219
internal coat, 19
lymphatics of, 19, 255
mucous coat, 19
repair of, 23
muscular coat, 18
repair of, 24
operations, 201

clamps for, 100
repair of, experimental research on, 20
resections of, extensive, clamps for, 100
serous coat, 17

repair of, 24
structure of, 17
submucous coat, 18

repair of, 41
ulcer of, excision of, 276-281
Vallas's method, 276
Stretching pylorus, 211
Hahn's method, 217
Loreta's method, 212
Stricture, non-malignant, of pylorus, operations
for, 218
of intestine, 129
Submucous coat of stomach and intestine, 18

repair of, 41
Subpyloric chain of glands, 256
Surgeon's knot, 79
Suture, buttonhole, 90

Connell's through-and-through mattress, 91

Cushing right-angle continuous, 81

Glover's, 8g

Heister's, 90

in two layers, formation of blind end of intestine

by, 158
Jobert-Senn, 92
leakage of, causes, 65
Lembert, 83
materials, 65
mattress, 84

end-to-end anastomosis by, 145-150

Gould, 85

Halsted, 84

lateral intestinal anastomosis by, 164

mesenteric, 91

Suture, Maunsell's mattress mesenteric, 91
plain, experiments with, 22
table of, 22

gastroenterostomy by, seventeen months, 39

lateral intestinal anastomosis by, 162
purse-string, 86

formation of blind end of intestine by, 160

Murphy, 88
Senn-Jobert, 92
seromuscular, 80

penetrating mattress, 92
special technic of, 79
through-and-through continuous, 89

mattress, 91

Technic, special, of sutures, 79
Temporary colostomy, 183

Thickness and transparency of mesentery in in-
testinal localization, 118

of intestine in localization, 117
Through-and-through continuous suture, 89

mattress suture, 91
Transverse colon, lymphatics of, in
Tube, glass, colostomy with, 196
Tunica propria, 19
Tying knots, 70-75

square knots, 70-75

Ulcer of stomach, excision of, 276-281
Vallas's method, 276
peptic, of jejunum, after gastroenterostomy, 43,

49
etiology, 43
frequency, 43
pathology, 45

Vallas's method of excision of ulcer of stomach,

276
Valvulee conniventes of intestine, 117
Vasa brevia, 250

Vermiform appendix, burying stump of, 85,
86

collecting trunks of, anatomy, 112

lymphatics of, in
Vicious circle, 220
Von Hacker's gastroenterostomy, 237

Witzel's gastrostomy, 206-210
Wblfler's gastroenterostomy, 246

gastrogastrostomy, 282
Wounds, intestinal, repair of, 1 7

SAUNDERS* BOOKS

GYNECOLOGY

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W. B. SAUNDERS COMPANY

925 WALNUT STREET PHILADELPHIA

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SAUNDERS' TEXT-BOOKS CONTINUE TO GAIN

EACH year in the list of text-books recommended in the various colleges a
decided gain is shown for the Saunders publications. This year in the list of
recommended books published by 166 colleges (the other 22 did not publish lists)
the Saunders books are mentioned 3054 times, as against 2759 the previous year
— an increase of 295. What these figures really mean is that in each of the
medical colleges in this country an average of 1854 { l 7]4 tne previous year) of
the teaching books employed are publications issued by W. B. Saunders Company.
And this increase is not due alone to the publication of new text-books, but to a
very gratifiying increase in the recommendation of text-books of some years'
standing — books that, because of their recognized superiority, have become
standard. For instance: Anders' Practice shows an increase of 15 ; Ashton's
Gynecology, an increase of 23 ; Boston's Clinical Diagnosis, 13 ; Draper's Legal
Medicine, 10; Hirst's Diseases of Women, 13 ; Holland's Chemistry, 22 ; Howell's
Physiology, 54 ; Sahli's Diagnostic Methods, 33 ; Stelwagon's Diseases of the
Skin, 13. These are but examples of similar remarkable gains throughout the
entire list, and is undoubted evidence that the Saunders text-books are
recognized as the best on their several subjects.

A Complete Catalogue of our Publications will be Sent upon Request

SAUNDERS' BOOKS ON

StelwagonV
Diseases of the Skin

A Treatise on Diseases of the Skin. For Advanced Students and
Practitioners. By Henry W. Stelwagon, M. D., Ph. D., Professor of
Dermatology in the Jefferson Medical College, Philadelphia. Hand-
some octavo volume of 1135 pages, with 258 text-cuts and 32 full-
page colored lithographic and half-tone plates. Cloth, $6.00 net;
Sheep or Half Morocco, $7.50 net.

JUST ISSUED — NEW (5th) EDITION
FIVE LARGE EDITIONS IN FIVE YEARS

The demand for five editions of this work in a period of five years, and the
many gratifying review notices indicate beyond a doubt the practical character of
the book. In preparing the work the predominant aim kept in view was to sup-
ply the physician with a treatise written on plain and practical lines, giving abun-
dant helpful case illustrations. In this edition the section on Tropical Skin
Diseases has been very thoroughly revised and a number of unusual illustrations
added. It is the most up-to-date work on skin diseases published.

PERSONAL AND PRESS OPINIONS

John T. Bowen, M.D.,

Assistant Professor of Dermatology, Harvard University Medical School, Boston.
" It gives me great pleasure to endorse Dr. Stelwagon's book. The clearness of description
is a marked feature. It is also very carefully compiled. It is one of the best text-books yet
published and a credit to American dermatology."

George T. Elliot, M. D..

Professor of Dermatology, Cornell University.

"It is a book that I recommend to my class at Cornell, because for conservative judgment,
for accurate observation, and for a thorough appreciation of the essential position of dermatol-
ogy, I think it holds first place."

Boston Medical and Surgical Journal

"We can cordially recommend Dr. Stelwagon's book to the profession as the best text-
book on dermatology, for the advanced student and general practitioner, that has been brought
strictly up to date. . . . The photographic illustrations are numerous, and many of them are
of great excellence."

DISEASES OF THE EYE.

DeSchweinitz's
Diseases of the Eye

Just Issued— The New (5th) Edition, Enlarged

Diseases of the % Eye : A Handbook of Ophthalmic Practice.
By G. E. DeSchweinitz, M.D., Professor of Ophthalmology in the Uni-
versity of Pennsylvania, Philadelphia, etc. Handsome octavo of 894
pages, 313 text-illustrations, and 6 chromo-lithographic plates. Cloth,
#5.00 net; Sheep or Half Morocco, $6.50 net.

WITH 313 TEXT-ILLUSTRATIONS AND 6 COLORED PLATES

For this new edition the text has been very thoroughly revised, and the work
enlarged by the addition of new matter to the extent of some one hundred pages.
There have been added, amongst other subjects, chapters on the following : X-Ray
Treatment of Epithelioma, Xeroderma Pigmentosum ; Purulent Conjunctivitis of
Young Girls ; Jequiritol and Jequiritol Serum ; X-ray Treatment of Trachoma ;
Infected Marginal Ulcer ; Keratitis Punctata Syphilitica ; Uveitis and Its Varieties ;
Eye- ground Lesions of Hereditary Syphilis ; Macular Atrophy of the Retina ;
Worth's Amblyoscope ; Stovain, Alypin ; Motais' Operation for Ptosis ; Kuhnt-
Miiller's Operation for Ectropion ; Haab's Method for Foreign Bodies ; and
Sweet's X-Ray Method of Localizing Foreign Bodies. Other chapters have been
rewritten. The excellence of the illustrative feature has been maintained.

PERSONAL AND PRESS OPINIONS

Samuel Theobald, M.D.,

Clinical Professor of Ophthalmology, Johns Hopkins University, Baltimore.
" It is a work that I have held in high esteem, and is one of the two or three books upon
the eye which I have been in the habit of recommending to my students in the Johns Hopkins
Medical School."

W. Franklin Coleman, M. D.,

Professor of Diseases of the Eye, Postgraduate Medical School, Chicago.

"I am very much pleased with deSchweinitz's work and will recommend it to the members
of my class as a most reliable, complete, and up to date text-book."

British Medical Journal

"A clearly written, comprehensive manual. One which we can commend to students as a
reliable text-book, written with an evident knowledge of the wants of those entering upon the
study of this special branch of medical science."

SAUNDERS' BOOKS ON

Webster's
Diseases of Women

With Beautiful Illustrations

A Text-Book of Gynecology. By J. Clarence Webster, M. D.
(Edin.), F. R. C. P. E., Professor of Gynecology and Obstetrics in Rush
Medical College, in Affiliation with the University of Chicago ; Obstetri-
cian and Gynecologist to the Presbyterian Hospital, Chicago. Large
octavo volume of 712 pages, with 372 magnificent text-illustrations and
10 colored plates. Cloth, $7.00 net; Half Morocco, $8.50 net.

JUST READY— FOR THE PRACTITIONER

This entirely new work on diseases of women is based on Dr. Webster's
extended clinical experience, and unusual prominence is given "to the scienti-
fic basis of each subject under consideration. Special endeavor has been made
to include all the important original investigations of recent years, so that the work
represents the present-day knowledge upon a subject of the greatest importance to
every practitioner. Indeed, Dr. Webster has written this work especially for the
general practitioner, discussing the clinical features of the subject in their widest
relations to general practice rather than from the standpoint of specialism. The
magnificent illustrations, three hundred and seventy-two in number, are nearly all
original. Drawn by expert anatomic artists under Dr. Webster's direct super-
vision, they portray the anatomy of the parts and the steps in the operations with
rare clearness and exactness. These illustrations, selected because of their
practical and technical value, form a rich collection, supplementing a text of
unusual conciseness.

Howard A. Kelly, M.D.,

Professor of Gynecology, Johns Hopkins University,

" It is undoubtedly one of the best works which has been put on the market within recent
years, showing from start to finish Dr. Webster's well-known thoroughness. The illustrations
are also of the highest order.

OBSTETRICS.

Webster's
Text-Book of Obstetric/*

A Text-Book of Obstetrics. By J. Clarence Webster,. M.JD. (Edin.),
F. R. C. P. E., Professor of Obstetrics and Gynecology in Rush Medical
College, in Affiliation with the University of Chicago ; Obstetrician and
Gynecologist to the Presbyterian Hospital, Chicago. Handsome octavo
volume of 767 pages, beautifully illustrated, including many in colors.
Cloth, $5.00 net; Sheep or Half Morocco, #6.50 net.

RECENTLY ISSUED— BEAUTIFULLY ILLUSTRATED

This entirely new work is written for the student of obstetrics as well as for
the active practitioner. The anatomic changes accompanying pregnancy, labor,
and the puerperium are described more fully and lucidly than in any other text-
book on the subject. The exposition of these sections is based mainly upon
studies of frozen specimens, in which department the author has had a larger
experience than any other worker. Unusual consideration is given to embryo-
logic and physiologic data of importance in their relation to obstetrics. Great
care was taken in the selection of the illustrations, aiming to meet the varied re-
quirements of both the undergraduate and the practising physician. The book
expresses the most advanced thought of the day.

OPINIONS OF THE MEDICAL PRESS

Medical Record, New York

" The author's remarks on asepsis and antisepsis are admirable, the chapter on eclampsia
is full of good material, and . . . the book can be cordially recommended as a safe guide."

Buffalo Medical journal

" As a practical text-book on obstetrics for both student and practitioner, there is left very
little to be desired, it being as near perfection as any compact work that has been published."

Dublin Journal of Medical Science

" Both to the student . . . and to the practitioner who requires the latest opinion on any
point of practice, Dr. Webster's book will be of the greatest value."

SAUNDERS' BOOKS ON

Brtihl, Politzer, arid Smith's
Otology

Atlas and Epitome of Otology. By Gustav Bruhl, M. D., of
Berlin, with the collaboration of Professor Dr. A. Politzer, of
Vienna. Edited, with additions, by S. MacCuen Smith, M.D., Pro-
fessor of Otology in the Jefferson Medical College, Philadelphia.
With 244 colored figures on 39 lithographic plates, 99 text illustra-
tions, and 292 pages of text. Cloth, $3.00 net. In Saunders' Hand-
Atlas Series

INCLUDING ANATOMY AND PHYSIOLOGY

The work is both didactic and clinical in its teaching. A special feature is
the very complete exposition of the minute anatomy of the ear, a working knowl-
edge of which is so essential to an intelligent conception of the science of otology.
The association of Professor Politzer and the use of so many valuable specimens
from his notably rich collection especially enhance the value of the treatise. The
work contains everything of importance in the elementary study of otology.

Clarence J. Blake, M. D.,

Professor of Otology in Harvard University Medical School, Boston.

" The most complete work of its kind as yet published, and one commending itself to both
the student and the teacher in the character and scope of its illustrations."

Haab arid deSchweinitz's
Operative Ophthalmology

Atlas and Epitome of Operative Ophthalmology. By Dr. O.

Haab, of Zurich. Edited, with additions, by G. E. de Schweinitz,
M. D., Professor of Ophthalmology in the University of Pennsylvania.
With 30 colored lithographic plates, 154 text-cuts, and 375 pages of
text. In Saunders' Hand-Atlas Series. Cloth, $3.50 net.

RECENTLY ISSUED

Dr. Haab's Atlas of Operative Ophthalmology will be found as beautiful and
as practical as his two former atlases. The work represents the author' s thirty
years' experience in eye work. The various operative interventions are described
with all the precision and clearness that such an experience brings. Recognizing
the fact that mere verbal descriptions are frequently insufficient to give a clear
idea of operative procedures, Dr. Haab has taken particular care to illustrate
plainly the different parts of the operations.

Johns Hopkins Hospital Bulletin

" The descriptions of the various operations are so clear and full that the volume can well
hold place with more pretentious text-books."

DISEASES OF THE EYE.

Haab and DeSchweinitz's
External Diseases qf the Eye

Atlas and Epitome of External Diseases of the Eye. By Dr. 0.

Haab, of Zurich. Edited, with additions, by G. E. deSchweinitz,
M. D., Professor of Ophthalmology, University of Pennsylvania. With
98 colored illustrations on 48 lithographic plates and 232 pages of
text. Cloth, $3.00 net. In Saunders' Hand-Atlas Series.

SECOND REVISED EDITION— RECENTLY ISSUED

Conditions attending diseases of the external eye, which are often so complicated,
have probably never been more clearly and comprehensively expounded than in
the forelying work, in which the pictorial most happily supplements the verbal
description. The price of the book is remarkably low.

The Medical Record, New York

" The work is excellently suited to the student of ophthalmology and to the practising
physician. It cannot fail to attain a well-deserved popularity."

Haab and DeSchweinitzV
Ophthalmoscopy

Atlas and Epitome of Ophthalmoscopy and Ophthalmoscopic
Diagnosis. By Dr. O. Haab, of Zurich. From the Third Revised
and Enlarged German Edition. Edited, with additions, by G. E.
deSchweinitz, M. D., Professor of Ophthalmology, University of
Pennsylvania. With 152 colored lithographic illustrations and 85
pages of text. Cloth, $3.00 net. In Saunders' Hand-Atlas Series.

The great value of Prof. Haab's Atlas of Ophthalmoscopy and Ophthalmo-
scopic Diagnosis has been fully established and entirely justified an English
translation. Not only is the student made acquainted with carefully prepared
ophthalmoscopic drawings done into well-executed lithographs of the most im-
portant fundus changes, but, in many instances, plates of the microscopic lesions
are added. The whole furnishes a manual of the greatest possible service.

The Lancet, London

"We recommend it as a work that should be in the ophthalmic wards or in the library of
every hospital into which ophthalmic cases are received."

SAUNDERS- BOOKS ON

Penrose's
Diseases of Women

Fifth Revised Edition

A Text-Book of Diseases of Women. By Charles B. Penrose,
M. D., Ph. D., formerly Professor of Gynecology in the University of
Pennsylvania; Surgeon to the Gynecean Hospital, Philadelphia. Oc-
tavo volume of 550 pages, with 225 fine original illustrations. Cloth,

#3-75 net.

RECENTLY ISSUED

Regularly every year a new edition of this excellent text-book is called for,
and it appears to be in as great favor with physicians as with students. Indeed,
this book has taken its place as the ideal work for the general practitioner. The
author presents the best teaching of modern gynecology, untrammeled by anti-
quated ideas and methods. In every case the most modern and progressive
technique is adopted, and the main points are made clear by excellent illustra-
tions. The new edition has been carefully revised, much new matter has been
added, and a number of new original illustrations have been introduced. In its
revised form this volume continues to be an admirable exposition of the present
status of gynecologic practice.

PERSONAL AND PRESS OPINIONS

Howard A. Kelly. M. D.,

Professor of Gynecology and Obstetrics, 'Johns Hopkins University, Baltimore.
" I shall value very highly the copy of Penrose's ' Diseases of Women ' received. I have
already recommended it to my class as THE BEST book."

E. E. Montgomery, M. D„

Professor of Gynecology, Jefferson Medical College, Philadelphia.
" The copy of ' A Text-Book of Diseases of Women ' by Penrose, received to-day. I have
looked over it and admire it very much. I have no doubt it will have a large sale, as it justly
merits."

Bristol Medico-Chirurgical Journal

" This is an excellent work which goes straight to the mark. . . . The book may be taken
as a trustworthy exposition of modern gynecology."

G YNE CO LOGY AND OBS TE TRICS.

The American
Text-Book of Obstetric/*

Second Edition, Thoroughly Revised and Enlarged

The American Text=Book of Obstetrics. In two volumes. Edited
by Richard C. Norris, M.D., Assistant Professor of Obstetrics in the
University of Pennsylvania; Art Editor, Robert L. Dickinson, M.D.,
Assistant Obstetrician, Long Island College Hospital, N. Y. Two
handsome octavo volumes of about 600 pages each; nearly 900 illus-
trations, including 49 colored and half-tone plates. Per volume:
Cloth, $3.50 net ; Sheep or Half Morocco, $4.50 net.

RECENTLY ISSUED— IN TWO VOLUMES

I
Since the appearance of the first edition of this work many important advances
have been made in the science and art of obstetrics. The results of bacteriologic
and of chemicobiologic research as applied to the pathology of midwifery ; the wider
range of the surgery of pregnancy, labor, and of the puerperal period, embrace
new problems in obstetrics. In this new edition, therefore, a thorough and critical
revision was required, some of the chapters being entirely rewritten, and others
brought up to date by careful scrutiny. A number of new illustrations have been
added, and some that appeared in the first edition have been replaced by others
of greater excellence. By reason of these extensive additions the new edition
has been presented in two volumes, in order to facilitate ease in handling. The
price, however, remains unchanged.

PERSONAL AND PRESS OPINIONS

Alex. J. C. Skene, M. D.,

Late Professor of Gynecology, Long Island College Hospital, Brookiyn.
" Permit me to say that ' The American Text-Book of Obstetrics ' is the most magnificent
medical work that I have ever seen. I congratulate you and thank you for this superb work,
which alone is sufficient to place you first in the ranks of medical publishers."

Matthew D. Mann, M. D.,

Professor of Obstetrics and Gynecology in the University of Buffalo.

" I like it exceedingly and have recommended the first volume as a text-book for out
sophomore class. It is certainly a most excellent work. I know of none better."

American journal of the Medical Sciences

" As an authority, as a book of reference, as a ' working book ' for the student or practi
Soner, we commend it because we believe there is no better."

SAUNDERS' BOOKS ON

Greene and Brooks 9
Genito-Urinary Diseases

A Text=Book of Genito-Urinary Diseases. By Robert H. Greene,
M. D., Professor of Genito-Urinary Surgery at Fordham University ;
and Harlow Brooks, M. D., Assistant Professor of Pathology, Univer-
sity and Bellevue Hospital Medical School. Octavo of 550 pages,
profusely illustrated.

JUST READY

This new work covers completely the subject of genito-urinary diseases, pre-
senting both the medical and surgical sides. It has been designed as a work of
quick reference, and has therefore been written in a clear, condensed style, so
that the information can be readily grasped and retained. Kidney diseases are
very elaborately detailed, and especially well presented is surgery of the kidney.
The text is profusely illustrated with original line-drawings.

Gleason on Nose, Throat,
and Ear

A Manual of Diseases of the Nose, Throat, and Ear. By E.

Baldwin Gleason, M. D., LL. D., Clinical Professor of Otology,
Medico-Chirurgical College, "Philadelphia. i2mo of 556 pages, pro-
fusely illustrated. Flexible leather, $2.50 net.

JUST ISSUED

Anatomy, physiology, and pathology of the upper respiratory tract and ear
have been carefully presented, the author rightly believing such knowledge essen-
tial to the efficacious treatment of diseases of these organs. Methods of treat-
ment have been simplified as much as possible, so ttiat in most instances only
those methods, drugs, and operations have been advised which have proved
essential. A valuable feature consists of the collection of formulas.

American Text=Book of Qenito=Urinary Diseases, Syphilis, and
Diseases of the Skin. Edited by L. Bolton Bangs, M. D., late
Professor of Genito-Urinary Surgery, University and Bellevue Hospital
Medical College, New York ; and W. A. Hardaway, M. D., Professor
of Diseases of the Skin, Missouri Medical College. Octavo, 1229
pages, 300 engravings, 20 colored plates. Cloth, $7.00 net.

DISEASES OF THE SKIN.

Mracek arid Stelwagon's
Diseases of the Skin

Atlas and Epitome of Diseases of the Skin. By Prof. Dr. Franz
Mracek, of Vienna. Edited, with additions, by Henry W. Stelwagon,
M. D., Professor of Dermatology in the Jefferson Medical College,
Philadelphia. With 77 colored plates, 50 half-tone illustrations, and
280 pages of text. In Saunders 1 Hand- Atlas Series. Clo., #4.00 net.

RECENTLY ISSUED— NEW (2nd) EDITION

This volume, the outcome of years of scientific an"d artistic work, contains,
together with colored plates of unusual beauty, numerous illustrations in black,
and a text comprehending the entire field of dermatology. The illustrations are
all original and prepared from actual cases in Mracek' s clinic, and the execution
of the plates is superior to that of any, even the most expensive, dermatologic
atlas hitherto published.

American Journal of the Medical Sciences

" The advantages which we see in this book and which recommend it to our minds are:
First, its handiness ; secondly, the plates, which are excellent as regards drawing, color, and the
diagnostic points which they bring out."

Mracek arid Bangs'
Syphilis and Venereal

Atlas and Epitome of Syphilis and the Venereal Diseases.

By Prof. Dr. Franz Mracek, of Vienna. Edited, with additions, by
L. Bolton Bangs, M. D., late Prof, of Genito-Urinary Surgery, Univer-
sity and Bellevue Hospital Medical College, New York. With 71
colored plates and 122 pages of text. Cloth, $3.50 net. In Saunders'
Hand-Atlas Series.

# CONTAINING 71 COLORED PLATES

According to the unanimous opinion of numerous authorities, to whom the
original illustrations of this book were presented, they surpass in beauty anything
of the kind that has been produced in this field, not only in Germany, but
throughout the literature of the world.

Robert L. Dickinson, M. D.,

Art Editor of " The American Text-Book of Obstetrics."
" The book that appeals instantly to me for the strikingly successful, valuable, and graphic
character of its illustrations is the ' Atlas of Syphilis and the Venereal Diseases.' I know of
nothing in this country that can compare with it."

I* SAUNDERS' BOOKS ON

Borland's
Modern Obstetrics

Modern Obstetrics: General and Operative. By W. A. Newman
Dorland, A. M., M. D., .Assistant Instructor in Obstetrics, Univer-
sity of Pennsylvania; Associate in Gynecology in the Philadelphia
Polyclinic. Handsome octavo volume of 797 pages, with 201 illustra-
tions. Cloth, $4.00 net.

Second Edition, Revised and Greatly Enlarged

In this edition the book has been entirely rewritten and very greatly enlarged.
Among the new subjects introduced are the surgical treatment of puerperal sepsis,
infant mortality, placental transmission of diseases, serum-therapy of puerperal
sepsis, etc. By new illustrations the text has been elucidated, and the subject pre-
sented in a most instructive and acceptable form.

Journal of the American Medical Association

" This work deserves commendation, and that it has received what it deserves at the hands
of the profession is attested by the fact that a second edition is called for within such a short
time. Especially deserving of praise is the chapter on puerperal sepsis."

Davis 9 Obstetric and
Gynecologic Nursing

Obstetric and Gynecologic Nursing. By Edward P. Davis, A. M.,
M. D., Professor of Obstetrics in the Jefferson Medical College and
Philadelphia Polyclinic; Obstetrician and Gynecologist, Philadelphia
Hospital. i2mo of 400 pages, illustrated. Buckram, $1.75 net.
RECENTLY ISSUED— SECOND REVISED EDITION

Obstetric nursing demands some knowledge of natural pregjiancy, and gyne-
cologic nursing, really a branch of surgical nursing, requires special instruction
and training. This volume presents this information in the most convenient
form. This second edition has been very carefully revised throughout, bringing
the subject down to date.

The Lancet, London

" Not only nurses, but even newly qualified medical men, would learn a great deal by a
perusal of this book. It is written in a clear and pleasant style, and is a work we can recom-
mend."

GYNECOLOGY AND OBSTETRICS. 13

Schaffer and Edgar's

Labor and Operative Obstetrics

Atlas and Epitome of Labor and Operative Obstetrics. By Dr.

0. Schaffer, of Heidelberg. From the Fifth Revised and Enlarged
German Edition. Edited, with additions, by J. Clifton Edgar, M. D.,
Professor of Obstetrics and Clinical Midwifery, Cornell University Medi-
cal School, New York. With 14 lithographic plates in colors, 139 other
illustrations, and in pages of text. Cloth, $2.00 net. In Saunders'
Hand-Atlas Series.

This book presents the act of parturition and the various obstetric operations
in a series of easily understood illustrations, accompanied by a text treating the
subject from a practical standpoint. 1 The author has added many accurate repre-
sentations of manipulations and conditions never before clearly illustrated.

American Medicine

"The method of presenting obstetric operations is admirable. The drawings, representing
original work, have the commendable merit of illustrating instead of confusing. It would be
difficult to find one hundred pages in better form or containing more practical points for
students or practitioners."

Schaffer and Edgar's

Obstetric Diagnosis and Treatment

Atlas and Epitome of Obstetric Diagnosis and Treatment. By

Dr. O. Schaffer, of Heidelberg. From the Second Revised German
Edition. Edited, with additions, by J. Clifton Edgar, M. D., Professor
of Obstetrics and Clinical Midwifery, Cornell University Medical School,
N. Y. With 122 colored figures on 56 plates, 38 text-cuts, and 315
pages of text. Cloth, $3.00 net. In Saunders' Hand-Atlas Series.

This book treats particularly of obstetric operations, and, besides the wealth
of beautiful lithographic illustrations, contains an extensive text of great value.
This text deals with the practical, clinical side of the subject. The symptoma-
tology and diagnosis are discussed with all necessary fullness, and the indications
for treatment are definite and complete.

New York Medical Journal

" The illustrations are admirably executed, as they are in all of these atlases, and the text
can safely be commended, not only as elucidatory of the plates, but as expounding the scien-
tific midwifery of to-day." 1

14 SAUNDERS' BOOKS ON

Ogden on the Urine

Clinical Examination of Urine and Urinary Diagnosis. A Clinical
Guide for the Use of Practitioners and Students of Medicine and Sur-
gery. By J. Bergen Ogden, M. D., Late Instructor in Chemistry,
Harvard University Medical School; Formerly Assistant in Clinical
Pathology, Boston City Hospital. Octavo, 418 pages, 54 illustrations,
and a number of colored plates. Cloth, $3.00 net.

SECOND REVISED EDITION— RECENTLY ISSUED

In this edition the work has been brought absolutely down to the present day.
Important changes have been made in connection with the determination of Urea,
Uric Acid, and Total Nitrogen ; and the subjects of Cryoscopy and Beta-Oxybutyric
Acid have been given a place. Special attention has been paid to diagnosis by
the character of the urine, the diagnosis of diseases of the kidneys and urinary
passages ; an enumeration of the prominent clinical symptoms of each disease ;
and the peculiarities of the urine in certain general diseases.

The Lancet, London

" We consider this manual to have been well compiled ; and the author's own experience,
so clearly stated, renders the volume a useful one both for study and reference."

Vecki's Sexual Impotence

The Pathology and Treatment of Sexual Impotence. By Victor
G. Vecki, M. D. From the Second Revised and Enlarged German
Edition. i2mo volume of 329 pages. Cloth, $2.00 net.

THIRD EDITION, REVISED AND ENLARGED

The subject of impotence has but seldom been treated in this country in the
truly scientific spirit that its pre-eminent importance deserves, and this volume will
come to many as a revelation of the possibilities of therapeutics in this important
field. The reading part of the English-speaking medical profession has passed
judgment on this monograph. The whole subject of sexual impotence and its
treatment is discussed by the author in an exhaustive and thoroughly scientific
manner. In this edition the book has been thoroughly revised, and new matter
has been added, especially to the portion dealing with treatment.

Johns Hopkins Hospital Bulletin

" A scientific treatise upon an important and much neglected subject. . . . The treatment
of impotence in general and of sexual neurasthenia is discriminating and judicious."

CHEMISTRY, SKIN, AND VENEREAL DISEASES. 15

American Pocket Dictionary Fifth Edition. Re™ed

The American Pocket Medical Dictionary. Edited by W. A.
Newman Dorland, M. D., Assistant Obstetrician to the Hospital
of the University of Pennsylvania. Containing the pronunciation
and definition of the principal words used in medicine and kindred
sciences. Flexible leather, with gold edges, $1.00 net; with thumb
index, $1.25 net.
James W. Holland, M. D.,

Professor of Medical Chemistry and Toxicology, and Dean, Jefferson Medical College,
Philadelphia,

" I am struck at once with admiration at the compact size and attractive exterior. I
can recommend it to. our students without reserve."

Stelwagon's Essentials of Skin "^SStSS 00

Essentials of Diseases of the Skin. By Henry W. Stel-
wagon, M. D., Ph.D., Professor of Dermatology in the Jeffer-
son Medical College, Philadelphia. Post-octavo of 276 pages,
with 72 text-illustrations and 8 plates. Cloth, $1.00 net. In
Saunders' Question- Comp end Series.
The Medical News

" In line with our present knowledge of diseases of the skin. . . . Continues to main-
tain the high standard of excellence for which these question compends have been noted."

Wolffs Medical Chemistry a tJ^taS3 tad

Essentials of Medical Chemistry, Organic and Inorganic.
Containing also Questions on Medical Physics, Chemical Physiol-
ogy, Analytical Processes, Urinalysis, and Toxicology. By Law-
rence Wolff, M. D., Late Demonstrator of Chemistry, Jefferson
Medical College. Revised by Smith Ely Jelliffe, M. D., Ph.D.,
Professor of Pharmacognosy, College of Pharmacy of the City of
New York. Post-octavo of 222 pages. Cloth, $1.00 net. In
Saunders' Question- Comp end Series.

Martin's Minor Surgery, Bandaging, and the Venereal

Diseases Second Edition, Revised

Essentials of Minor Surgery, Bandaging, and Venereal
Diseases. By Edward Martin, A. M., M. D., Professor of Clin-
ical Surgery, University of Pennsylvania, etc. Post-octavo, 166
pages, with 78 illustrations. Cloth, $1.00 net. In Saunders'
Question- Compend Series.

Senn's Genito-Urinary Tuberculosis

Tuberculosis of the Genito-Urinary Organs, Male and
Female. By N. Senn, M. D., Ph. D., LL. D., Professor of Surgery
in Rush Medical College. Octavo of 317 pages, illustrated.
Cloth, $3.00 net.

16 SAUNDERS' BOOKS ON GYNECOLOGY AND OBSTETRICS.

. . _ , . -~. ,. Fifth Revised Edition

American Pocket Dictionary just issued

The American Pocket Medical Dictionary. Edited by W,
A. Newman Dorland, AM., M. D., Assistant Obstetrician to the
Hospital of the University of Pennsylvania ; Fellow of the American
Academy of Medicine. Over 550 pages. Full leather, limp, with
gold edges. $1.00 net; with patent thumb index, $1.25 net.

James W. Holland, M. D..

Professor of Medical Chemistry and Toxicology at the Jefferson Medical College,

Philadelphia.
" I am struck at once with admiration at the compact size and attractive exterior. I
can recommend it to our students without reserve."

Recently Issued

Cragin' s Gynecology. , n«w (6th) Edition

Essentials of Gynecology. By Edwin B. Cragin, M. D.,
Professor of Obstetrics, College of Physicians and Surgeons, New
York. Crown octavo, 215 pages, 62 illustrations. Cloth, $1.00
net. In Saunders' Question- Compend Series-

The Medical Record, New York

" A handy volume and a distinct improvement of students' compends in general.
No author who was not himself a practical gynecologist could have consulted the
student's needs sc thoroughly as Dr. Cragin has done."

Boisliniere's Obstetric Accidents, Emergencies, and
Operations

Obstetric Accidents, Emergencies, and Operations. By
the late L. Ch. Boisliniere, M. D., Emeritus Professor of Ob-
stetrics, St. Louis Medical College ; Consulting Physician, St. Louis
Female Hospital. 381 pages, illustrated. Cloth, $2.00 net.

British Medical Journal

" It is clearly and concisely written, and is evidently the work of a teacher and practi-
tioner of large experience. Its merit lies in the judgment which comes from experience."

AshtOn'S Obstetrics. Recently Issued— New (6th) Edition

Essentials of Obstetrics. By W. Easterly Ashton, M. D.,
Professor of Gynecology in the Medico-Chirurgical College, Phila-
delphia. Crown octavo, 256 pages, 75 illustrations. Cloth, $1.00
net. In Saunders' Question-Compend Series.

Southern Practitioner

"An excellent little volume containing correct and practical knowledge. An admir-
able compend, and the best condensation we have seen."

Barton and Wells' Medical Thesaurus Recently issued

A Thesaurus of Medical Words and Phrases. By Wilfred
M. Barton, M. D., Assistant to Professor of Materia Medica and
Therapeutics, Georgetown University,- Washington, D. C. ; and
Walter A. Wells, M. D., Demonstrator of Laryngology, George-
town University, Washington, D. C. i2mo of 534 pages. Flex-
ible leather, #2.50 net ; with thumb index, $3.00 net.